Practical observations on aural surgery and the nature and treatment of diseases of the ear

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WORKS BY W. R. WILDE.

NARRATIVE

OF

A VOYAGE TO MADEIRA, TENERIFFE, AND ALONG
THE SHORES OF THE MEDITERRANEAN;

! INCLUDIXO A VISIT TO

ALGIERS, EGYPT, PALESTINE, TY&B, KH0DB3, TEUCESSUS, CYPRUS, AND GREECE :

With Observations on the present State and Prospects of Egypt and Palestine,
and on tha Climate^ Natural History, and Antiquities of

the Coontries visited.

Second Edition, enlarged, with Maps and other Illustrations. 8vo.

AUSTRIA : ITS LITERARY, SCIENTIFIC, AND MEDICAL

INSTITUTIONS ;

With Notes on the State of Science, and a Guide to the Hospitals and Sanitory

Establishments of Vienna. Crown 8vo.

THE CLOSING YEARS OF DEAN SWIFT'S LIFE :

With Bemarks on Stella, and on lome of his Writings hitherto unnoticed.

Second Edition, enlarged, with Portrait of Stella, and other

Illustrations. 8vo.

THE BOTNE AND THE BLACKWATER:

lllustrattb ^iBioruallg nxib iropogrupljunlln.

Second Edition, enlarged, with a Map, an Itinerary, Plan of the Battle of the Boync,
and Eighty-four Illustrations engraved on Woud. Cruwn 8vo.

IRISH POPULAR SUPERSTITIONS.

Crown 8vo.

OBSERVATIONS

Ul'OX

THE EPIDEMIC OPHTHALMIA

Which has provailed in the Irish Workhouses.

8vo.

In the rrets.

THE CONGENITAL MALFORMATIONS AND DISEASES OF

THE ORGANSQE^GHT.

PRACTICAL OBSERVATIONS

OM

AURAL SURGERY

AND

THE NATTJBE AND TBEATMENT

OF

DISEASES OF THE EAR,

WITH ILLUSTRATIONS.

BY

WILLIAM R. WILDE,

wwLLcm or the botal ooujeob op bdroiohs nr ibkulMDi sdbobom to n. mark'm ophthalmic hohpitali

BOMOBAKT MBfMB OP Tin BOTAL MBDIOAL SOCnriT OP BrOCKHOLIf ,

KtV» BTC.

LONDON:
JOHN CHURCHILL, PRINCE'S-STREET, SOHO.

DUBMN : FANNIN & CO. EDINBURGH : MACLACHLAN & CO.

MDCCCLIII.

/<^^.. a.. ///.

ouBLor:

BT M. H. OIUo

TO
HIS EXCELLENCV

EDWARD GRANVILLE, EARL OF ST. GERMANS,

LORD LIEUTENANT GENERAL AND GENERAL GOVEBNOE OF IRELAND.

ETC..

THIS WORK 18,

BY HIS EXCELLENCY'S PERMISSION,

AS A &LA.RK OF RESPECT FOR HIS PUBLIC CHARACTER,
AND OF PERSONAL GRATITUDE^

BY

THE AUTHOR.

PREFACE.

In the Introductory Chapter I have entered so fully into
the circumstances attending the publication of this work,
that but few prefatory observations are necessary. I
have laboured, and I trust not in vain, to expose error
and establish truth ; to lay down just principles for an
accurate diagnosis of Diseases of the Ear ; to rescue their
treatment from empiricism, and found it upon the well-
established laws of modem pathology, practical surgery,
and reasonable therapeutics. In dealing with my sub-
ject it was necessary to review the practice and opinions
of others : yet, though on certain points a conscientious
difference from other writers has been expressed, I have
not failed to award merit where merit was due.

My friend and former pupil, Dr. Addinell Hewson, of
Philadelphia, has consented to edit the American edition
of this book, now in course of publication by Messrs.
Blanchard and Lea ; and my friend Dr. von Haselberg,
of Stralsund, has kindly undertaken the translation of it
into German.

Dublin, 21, Westland-row,
June 12, 1853.

CONTENTS.

CHAPTER L

PAOB.
iKTRODUCnON AND BiBUOORAPHT, 1

CHAPTER II.
MicAifs OF DiAONoeis, 5t

CHAPTER III.
Statistics and Nosology of Ear Disbases, 97

CHAPTER IV.

DiSKASES OF THE AURICLR, BIaSTOID ReOION, AND EXTERNAL BfBATUS, ... 160

CHAPTER V.
Diseases of the Membrana Ttmpani, 210

CHAPTER VI.
Diseases of the Middle Ear and Eustaobian Tube, 811

CHAPTER VII.
Diseases op the Internal Ear, 871

CHAPTER VIIL
Otorrrcea, 894

APPENDIX.

DSAF-DtTMBNESS, , 486

IiTDSZ, 497

A TREATISE

OK

DISEASES OF THE EAR.

CHAPTER I.

IHTBODDCTIOB AHS BIBUOaBAFHT.

Iotn>di>ctoi7ltaiiaTkionAaral3argciy. — Former idwim of ii!UgiMiiU,«ndgai««l know-
ledge of the subject. Early History of tbe Art— Writings of the Andents tna

Hippocralea to Gslen.— Discoveries of the AnUomisU of thB aiteenth (Hitiiiy.— Irish
'TrusUtloDS.—HercarisUs.^InstnicliailDrUieDofuidEhimb — Hearnios. — JatiO'
ductioD ortheSpe<:nliuiib7Fsbridas._BoDet snd Da Verney — Kennedy.— Eusta-
diim CUfaeteriBD by Gnyot — English AoiiOs : Clelud sod W«lhuj.— la^Aerin.—

DfgTSTen. VsIssIts sod Cassebohm. — Sims snd the London Hedkal Sode^ —

Gnbun snd Elliott. Quacks and Quackerf. Perfoiation of Histoid Process^ —

Oieselden. — Porfontioa of tbe Membrana Tj-mpani liy Sir A. Cooper — Saunde™.
— Outii and his (bOowera ; Stephensan, WilUams, Wright, Webster, Hc?'""!^. *^
Gaidoer— BachansD, Esrk, Tod, Swan and Canrell — The French School ; Laennec,
Itsrd, and Deleau.— Ths Germaii School: Eruner, SchmaU, Lincke, snd Prsnk —
The Hodem BngUsh Scbool: Toynbee, Pitcher, Whaiton Jone^ Williams, Teanley,
Harvey, Dnlton, and Waketey. — Tamboll and Ms Boviewen.— Beqdsite* fin an
Anrsl SorgeoD, and what Aural Sarger; can etftct.

XN the following Treatise I purpose writing, for the information
-*~ of practitioners and studenta in medicine, the history, symp-
toms, causes, mode of treatment, and results of the moat frequent
and remarkable diseasesof the Ear. With rospeot to my competency
to this task, I have but to remark, that I have had very ample op-
portanities for studying these diseases during the last tea yean
in an extenmve practice, and in the management of a large public
institution in Dublin, for a long time the only one of the kind
open to the student where clinical and practical instruction in
Aural Surgery ma delivered in Great Britua.

2 INTRODUCTOfiT REMARKS.

This work is the result of the experience thus acquired. De-
tached portions of it, clinical lectures, and cases observed at St.
Mark's Hospital, have already appeared in the periodicals of this
country, and some of these essays have been translated and pub-
lished separately on the Continent. All these, together with much
additional information gleaned since their publication, are em-
bodied in this book, which does not profess to be a complete sys-
tem of Aural Surgery, giving a full description of all the diseases of
the Ear which have been recorded by authors ; but is intended
to supply the reader with a practical treatise on the most frequent
and urgent affections of the organ of hearing, and those that I my-
self am best acquainted with. It may, therefore, be regarded some-
what in the light of a monograph, a form of publication peculiar
to this School, and one generally containing more useful and prac-
tical information than either a large systematic work or a manual.

In studying the diseases of the Ear, my object has been to
take as a basis the principles of pathology : and to reduce their
treatment, local as well as general, to the recognised rules of mo-
dem therapeutics and scientific surgery ; but, above all, I have
laboured to divest this branch of medicine of that shroud of
quackery, medical as well as popular, with which, until lately, it
has been encompassed.

Country friends often ask me, " Have you found out any new
cure for deafness T I do not profess to invent or introduce new
remedies. I try to make the well-established rules of practice in
the treatment of other organs applicable to the management of
aural diseases. Like most students, I was taught during my ap-
prenticeship theoretically to believe, and practically to observe,
that we *' knew nothing about the diseases of the organs of hear-
ing." This was the dictum honestly expressed by the " heads of
the Profession," — men from whom the public were willing to re-
ceive a fearless, candid opinion, either immediately on being con-
sulted, or after a few trials of the "ordinary means;" to wit,
syringing with hot water and soap, either Castile, soft, yellow, or
old brown Windsor, in the hope that the deafness or the noise in
the ears might arise from a collection of hardened wax ; — then
setting the digestive organs to rights by purgation, and a '< course

FORMER MEANS OF DIAGNOSIS AND TREATMENT. 3

of bitters," lest the affection might be " owing to the stomach."
The human stomach has much to answer for in deranging the
system generally, no doubt; but the mischief of which it is daily
accused, as every one extensively engaged in practice is well
aware, is beyond belief. There is scarcely a disease which we
treat, no matter how local, upon which, if we question the patient
as to its duration, that he will not say, " Oh I it is, indeed, of
pretty long standing, but I was waiting to have my stomach
put to rights, as I am told I am very bilious." Next in order,
blistering behind the ears is tried, in order to draw away some
peccant humour that had, perhaps^ accumulated round the deli-
cate organ of hearing. These and such like methods failing to give
relief, stimulants, often of a very acrid nature, are poured into
the external auditory passages, either to restore the secretion, — un-
der the impression that what is a mere attending symptom is the
disease, — or to excite or rouse the dormant nervous power; and
hot tinctures, turpentine, creasote, and pungent essential oils are
iCpplied to the external surface of the tympanal membrane with-
out mercy. Some practitioners resort to more palliative means,
recommending some warm almond oil to be dropped into the
ear at bedtime, or eau de Cologne to be rubbed upon the side of
the cheek adjoining the auricle, at the same time advising a lit-
tle black wool to be retained in the meatus, in order to preserve
the organ from cold. To give, however, fair play to the latter
remedy, it should be prescribed in full, and according to the
old popular superstition, but one which is still extensively re-
sorted to, — the wool should be procured from the left fore-foot of
a six years' old black ram ! Some advise a slice of fat bacon to
be inserted into the meatus every second night; and glycerine
is now the fashionable remedy. All these means having failed
to give relief, the patient is frequently recommended — an easy
mode of getting rid of him — to give galvanism and electricity
a fair trial ; and if they do not succeed, change of air and scene,
sea>bathing, or a '* course of waters" at some of the fashionable
places of resort for that purpose is prescribed. Despairing of
relief from the legalized practitioner, and getting disheartening

b2

4 CAU8B8 09 OPPROBRIUM IN AURAL 8URQEBT.

opinions from men of eminence and repute, we need not wonder
that suffering patients throw themselves into the hands of quacks
and nostrum-mongers.

Moreover, the difficulties which beset the student in ac-
quiring a knowledge of the anatomy of the ear, owing to the ex-
ceeding minuteness of the organ itself, the great difficulty of
dissecting it, from its depth, the complexity of its structure, and
the small, hard bone in which it is placed, as well as the number
of crabbed names attached to its different parts, all of which have
made it a sort of anatomical crux, which no one wishes to remem-
ber longer than the day after he has passed his examination, have
conduced not a little to strengthen the belief in the doctrine pro-
mulgated by his instructors, that little or nothing could be done
to reach the diseases of so delicate and intricate an organ.

Now, notwithstanding the remarks which we hear daily in
society, or which we meet with in the periodic and " manual** li-
terature of the day, — that the treatment of diseases of the ear is
an opprobrium to medicine, — the progress which this branch of
medical science is making is in all probability as rapid as that in
any other department of the healing art. Among the many
causes from which this opinion has arisen, there are two which
must pre-eminently attract the attention of any person conversant
with the subject, or who will calmly examine into the question.
The first is, that heretofore the treatment of those diseases has
been committed to the hands of the most uneducated quacks and
charlatans, male and female, — persons totally unacquainted with
the first rudiments of medical knowledge ; the second, that me-
dical men themselves — most astute and practical physicians and
surgeons in all other respects — treat diseases of the ear certainly
in a manner that savours of empiricism, by prescribing nostrums,
of both a local and general character, which we know they would
never think of using in similar forms of disease in any of the other
organs of the body. This latter cause evidently results from want
of proper attention to the subject in our schools, and from the
practice of prescribing at random for diseases, the diagnosis and
pathology of which are generally unknown.

INDIFFERENCE OF PATIENTS. 5

To both these causes may be added others that, to a certain
degree, serve to bias the public mind against the treatment of
aural diseases. In many cases, there is either an unconsciousness
of the insidious approaches of deafness, or an unwillingness to
admit even the possibility of such an occurrence ; or, again, there
is an apathy, to a greater or less degree, on the part of those af-
fected with deafness, and a delay in seeking advice, which is
scarcely credible. Persons who, if they suffer the least inconve-
nience in any of their functions, or the slightest interference with
the due exercise or healthy condition of any of the other organs
of sense, would immediately apply for medical relief, and submit
to any, even the most severe form of treatment, will patiently
permit the sense of hearing to be greatly impaired, nay, even lost
on one side, without making any effort for ift restoration. When
the lapse of months, and even years, have contributed to confirm
disease and render such persons incurable, they generally respond
to inquiries with regard to previous treatment, — that they did not
like to be '* tampering** with their ears, or, that they were told no-
thing could be done for them.

It would in no wise conduce to the practical effect to which I
hope this work may tend, to inquire into all the causes of these
results: I may, however, mention, that medical men themselves
have in part conduced to produce this want of faith on the part
of the public, either by direct opinion as to the incurable nature
of the disease or diseases known by the symptom of deafness, or
by such futile treatment as broke down the confidence of the pa-
tient in any remedy for diseases of the organs of hearing. It is
true that cases of what are termed ** nervous deafness,** that is, of
defect in the hearing function of the acoustic nerve in any part of
the internal ear, from paralysis or other causes, — or of those por-
tions of the brain which preside over the faculty of hearing, or
give origin to, or are connected with the portio mollis of the se-
venth pair of nerves, — in fact, such cases as are analogous to
amaurosis, — are as intractable as that disease of the eye; — yet I
fear not to reiterate the assertion which I made upon several for-
mer occasions, that if the diseases of the ear were as well studied
or understood by the generality of practitioners, and as early at-

6 THE EARLY HISTORY OF AURAL SURGERY,

tended to, as the diseases of the eye, it would be found that they
were just as much within the pale of scientific treatment

We have now several special works upon aural surgery, as
well as some valuable monographs thereon in the cyclopaedias and
periodicals, yet it is to be regretted that the modem systems of
surgery contain but scanty information upon the subject of dis-
eases of the ear. The following passage from M. Druitt's well-
arranged " Surgeons' Vade Mecum** (which is an exception to
the class) is so apposite to the foregoing observations, that I in-
sert it: — *' Deafness is so common and so distressing an infirmity,
and, when of long standing, is so incurable, that we cannot too
strongly urge all medical practitioners to make themselves fami-
liar with the treatment of diseases of the ear. They should also
encourage their pati<!hts to apply to them for the relief of Mffht
and indpierU ailments in this organ, instead of allowing them to
go on till they become permanently deaf, and then letting them
fruitlessly seek relief from ignorant and mercenary quacks.**

THE EARLY HISTORY OF AURAL SURGERY.

In the present day, when literature in every Protean shape and
form has compassed the land, and knowledge may truly be said
to run to and fro throughout the earth ; and when the polyglot
cyclopsedia of the Press has outstripped in the race all other feats
of human prowess of the nineteenth century, it might be deemed
unnecessary to follow the old school system of detailing the early
history of that particular branch of medicine of which this essay
treats, were it not that in an art but just emerging from the dark-
ness, ignorance, empiricism, prejudice, and superstition, which is
to a certain extent even yet the condition of aural surgery, its
history not only becomes interesting, but practically instructive.
Furthermore, as this work is not put forward as a system contain-
ing a compilation of opinions, or abounding in extracts and refe-
rences, but is chiefly the result of my own experience, the follow-
ing notices of the writings of others is given with a view of
directing the student to tlie most accessible sources of infor-
mation on the subject.

FBOH THE TIHEB 01 KIPPOCBITES XO CEISUB. 7

I might, with the generality of writers upon the history of
medicine, commence with the timea of Hippocrates, for he makes
several allusions to the affections of the organs of hearing, not,
however, &a idiopathic forms of disease, but as symptomatic of
other maladies of an acute or chronic nature ; but it must be
borne in mind that at that period of medical science (and, I regret
to add, that it has in a great part descended to the present day)
the affections of the ear, whether functional or organic, were
spoken of, lectured on, written of, and described, not according
to the laws of pathology which regulate other diseases, but by a
single symptom, that of deafness. " If," says Dr. Kramer, " I
mention that the treatment of deafness (viz. as it occurs as a func-
tional disorder only of the ear, without any perceptible external
alteration of the organ) merely consists of not washing out the
ear, but cleansing it with wool, dropping in oil, directing the pa-
tient to walk out, rise early, drink white wine, abstain from salads,
and allowing him to eat bread, and such fish as inhabit rocky
shores, I shall have collected all that is of most importance to
give an idea of acoustic medicine at that time."

To CelsuB, the successor of Hippocrates, we are indebted for
the first acknowledgment of the specific or independent forms of
aural disease; for having introduced the practice of ocular in-
spection of the auditory canal ; and for some general rulee for the
treatment of the inflammatory affections of the organs of hearing.
But this advance in aural medicine, which we owe to Celsus,
is more than counterbalanced by his introduction into practice of
those stimulating nostrums which were then, and have been since,
applied to the membrana tympani without discrimination; and
many of which are mode use of in the present day.

Gralen followed in the track of his great predecessor, and
although he advanced somewhat in symptomatology, and was
evidently better acquwnted with the causes of the inflammatory
diwases of the ear, yet he and his disciples so increased the num-
ber of remedial agents which were applied to the external meatus,
that we find aural medicine and surgery, toward the end of the
fifteenth century, but a collection of hard names, unconnected
symptoms, fanciful and absurd theories based on causes the most

8 WBITIH08 09 THB EARLY IEI8H PHT8ICIAV8.

improbable, and a category of medical subetances from the ani-
maJ, mineral, and vegetable kingdoms, principally, however,
composed of hot spices and stimulating applications, of which I
may mention castor, ox-gall, garlic, frankincense, opium, nitre,
euphorbium, alum, iron filings boiled on vinegar, hellebore, myrrh,
and many other such substances, each lauded by their respective
admirers, and extolled as panaceas for deafness in all its numerous
forms and modifications; as we find glycerine is at the present
day. Those who still prescribe such nostrums, and they are
many, might consult with advantage old '* Gbtbelhover's Boocke
of Physicke," printed in 1559.

It would afibrd us neither literary interest nor practical utility,
commensurate with the task, to detail the notions concerning the
treatment and diseases of the ear, as they may be found scattered
throughout the writings of Aurelianus, Paul of JEgina, Razes,
Serapion, Hali Abbas, Mesue, and Dioscorides; the works of the
three latter of whom were translated into Grselic by several distin-
guished Irish physicians from the beginning of the fourteenth to
the end of the sixteenth century.*

At the conclusion of the fifteenth century the anatomy of the
ear received a new impulse, by the investigations and discoveries
of some of the most distinguished anatomists and physicians of
that age, in compliment to whose labours subsequent writers gave
those parts names which we retain to the present day, as, the tube
of Eustachius, the aqueduct of Fallopius, the liquor of Cotunno,
and the fissure of Casserius ; but although these celebrated men
made the worid better acquainted with the anatomy of the organ
of hearing, and thus removed one of the chief obstacles to the in*
vestigation of aural pathology, their successors in medicine ad-
vanced but little in the diagnosis and treatment of diseases of the
ear.

The first special work upon the ear that I have been able to
discover is that of Heumius Mercurialis, ** De oculorum et aurium

* See the author't Introduction to the memoir on Vital Statistics in the Census of
Ireland for 1841 : and also a Lecture on the Early History of Irish Medicine, deliveied
at the College of Physicians, and published in the Medical Gazette fbr 18th February,
1848, et 9tq.

FIRST INSTRUCTION OF THE DEAF AND DUMB. 9

qffeetibw Prcdectiones^^ the first edition of which was published
at Frankfort in 1584. Mercurialis was chiefly a compilator from
the works of the Greeks, Romans, and Arabians, and as an origi-
nal investigator deserves no credit ; but he collected all that was
known and had been written before his day on aural diseases ; the
little he did add was that of a few more nostrumSf and, therefore,
he may be consulted with advantage by those of the fraternity
who still adhere to the good old rule of applying such remedies as
hot onions in acute inflammations of the meatus or tympanum.

In the sixteenth century the attention of philanthropists was
first turned towards the lamentable condition of the deaf and dumb.
Prior to that period, during those ages wont to be called enligh-
tened, and in those countries styled civilized and even refined —
among the Egyptians, Greeks, Romans, and Hebrews, the deaf
mute was, and even still in the Orient is, but little removed
from the brute, and is often employed for the basest and most de-
grading o£Sce8, such as humanity in the present day, in this coun-
try at least, shudders at. Up to that period the deaf and dumb
were not considered susceptible of improvement or instruction of
any kind, and their very passions, unrestrained by any influence,
human or divine, were frequently made to minister to the cruelty
or sensuality of those around them. I need not further enlarge
upon this subject here, as it is considered at length in the section
of this work devoted to deaf-dumbness.

The first book that treated of our subject in the seventeenth
century was a posthumous Latin work of Joseph Heurnius, on the
diseases of the organs of hearing, published by his son, the cele-
brated Otho Heurnius, in 1602. Lincke, however, says that he
was but a compiler. Heretofore the treatment of aural diseases
consbted, as already remarked, for the most part, in medicinal
agents and empirical nostrums; but in 1646 the principles of sur-
gery were brought to bear upon this class of afiections by the
master-mind of Fabricius von Hilden. His observations on the
extraction of foreign bodies, on polypi, and other diseases of the
external auditory conduit, are well worthy of perusal ; and to him
is generally ascribed the invention of the first speculum auris, as
well as the first ear instruments on record. His speculum was

10 LABOURS OF FABBICIU8 AMD DU VERVBT.

formed on the principle of the common forcepe-like instrument
still in use ; but from the following passage in a still older writer,
Peter do la Cerlata, '* per inspectionem ad aoUm trohendo amrem
et ampliando cum speculo aui alio imtrumenio^ we are led to be-
lieve that means were employed before his time for examining
the external auditory passage. Instruments of this kind, and for
this purpose, having been once recognised and employed by prac-
titioners, have since been variously modified, according to the in-
genuity of the inventor ; — ^yet their first introduction into practice
decidedly formed an epoch in aural surgery. Fabricius's obser-
vations, and the description of his instruments, will be found in
his " Opera Omnia."

The next work of any merit that appeared in connexion with
aural medicine was published by a Genevese anatomist, Theophi-
lus Bonet ; his observations, as they are set forth in his great work,
the *^ Sepulcretum vel Chirurgica Practicay^ were chiefly confined
to the pathology of the ear from dissection ; but in a practical
point of view he advanced little beyond the limits attained by his
predecessors.

Towards the conclusion of the seventeenth century aural sur-
gery received a new impulse from the talents and laborious in-
vestigations of the distinguished French anatomist, Du Vemey.
Of late it has become the fashion to decry the labours of this great
man — in my humble judgment, unjustly — for he was far in ad-
vance of his time, and although the pathological is not as volumi-
nous, nor perhaps as accurate as the anatomical part of his writings
on the organ of hearing, still he was a lucid painter, and a gra-
phic describer of disease. He was the first person who arranged
the diseases of the ear according to the anatomical structures af-
fected, as, into those of the outer ear and meatus, those of the mid-
dle ear or tympanum, and those of the internal ear or labyrinth.
From the times of £ustachius to the period on which we are now
engaged, we have no work upon the anatomy of the organ of
hearing equal to that of Du Vemey, and to this day it may be
consulted with advantage. Wo likewise are indebted to Du Ver-
ney far more than is generally acknowledged, or, perhaps, writers
are aware of, for having given the first impulse to anything like

EUSTACHIAN CATHERBTISM BT OUYOT. 11

a knowledge of aural anatomy and surgery in England ; for his
book, which was published in Paris in 1683, was translated into
English after his death, and published in London in 1737, being
thus, though a translation, the first special treatise in point of
time upon aural medicine or surgery in our language. This is
now very scarce, yet there can, I think, be little doubt but that
Mr. Saunders availed himself largely of it. However, to Du Ver-
ney, and not to Lallemand and Itard, we are indebted for the pre-
judice that up to this day exists with regard to the treatment of
otorrhoea. But the latter were the more reprehensible, as from the
age in which they lived, and the giant growth of medical know-
ledge subsequent to the time of the former, they should have
known better ; but I believe, like many modern practitioners, they
chose rather to transmit the prejudices of one hundred and fifty
years before, than take the trouble of investigating for themselves.

Without entering minutely into the history of aural medicine
during the latter part of the seventeenth century, which, after all,
would consist in the enumeration of the Latin writings of various
Continental authors, more curious than instructive, let us pass on
to the penultimate century of our own period, when aural medi-
cine first dawned in Great Britain.

Li 1713, Peter Kennedy published in London a little work
styled " Ophthalmographia, or, a Treatise on the Eye,^ to which
is added an Appendix of some of the diseases of the ear, wherein
is observed the communication between these two organs; the
latter part consists of about ten pages.

It is remarkable, that the discovery which Eustachius made
of the tube which bears his name had no practical influence upon
this branch of medicine, and that for nearly two hundred years
surgery made no effort at availing itself of this knowledge, for the
purpose of remedying diseases of the ear. Li 1724, M. Guyot, a
postmaster of Versailles, proposed to the Parisian Academy of
Sciences to inject the Eustachian tube, by means of a catheter in-
troduced through the mouth, for the removal of obstructions in
that canal, and also in the middle ear. It seems, however, that
the French academicians were not sufficiently aware of his valu-
able discovery, or at least proposal, for it is a question whether
he ever performed the operation himself

12 BH0LI8H AU&I8T8 — GLBLAHD.

In 1741, Archibald Cleland, an English army surgeon, pub-
lished in the Philosophical Transactions an account of ** instru-
ments proposed to remedy some kinds of deafness, proceeding from
obstructions in the external and internal auditory passages.** The
first of these consisted *' of a convex glass, three inches in diame-
ter, fixed in a handle, into which is lodged some wax candle^
which when lighted will dart the collected rays of light into the
bottom of the ear, or to the bottom of any cavity that can be
brought into a straigfu liner Insignificant and incomplete as this
instrument of Cleland undoubtedly was, it is, nevertheless, deserv-
ing of our attention, inasmuch as to it may be traced the subsequent
inspector auris of Deleau, of Itard, Buchanan, and Kramer. The
principal object of Cleland*s inspector for throwing a stream of
artificial light into the meatus was for the purpose of discovering
the presence of hardened cerumen, which he removed by means
of a jet of medicated steam, ** but if,** says he, '* this has not the
desired effect, and the person still remains deaf, the following in-
struments are made to open the Eustachian tube; if upon trial it
should be found to be obstructed, the passage is to be lubricated
by throwing a little warm water into it, by a syringe joined to a
flexible silver tube, which is introduced through the nose into
the oval opening of the duct, at the posterior opening of the nares,
towards the arch of the palate.** This catheter had affixed to it
a shecp*s ureter, to the other end of which was attached the
syringe, ** whereby warm water may be injected ; or they will
admit to blow into the Eustachian tube, and so force the air into
the barrel of the ear, and dilate the tube sufficiently for the dis-
charge of the excrementitious matter that may be lodged there.**
He likewise used probes, of the same size as the catheters, to ex-
plore the tube. Cleland was either unaware of, or disbelieved, the
account of Gxiyot*s having introduced an instrument into his own
Eustachian tube through the mouth, nineteen years before ; for in
his essay in the Philosophical Transactions he does not once allude
to the circumstance. To the English surgeon, however, is un-
doubtedly due the merit of having first introduced a catheter into
the Eustachian tube through the nose, the only certain way, I
believe, of performing such an operation.

In May, 1755, Mr. Jonathan Wathan published a more de-

JONATHAN WATHAN. 13

tailed essay in the Philosophical Transactions, on ** a method
proposed to restore the hearing when injured from an obstruction
of the tuba Eustachiana. This gentleman, who seems to have
been a good practical anatomist, as well as a dexterous surgeon,
had an opportunity of making a post-mortem examination in a
case of deafness, wherein it was found that both Eustachian tubes
were " stuffed quite full of congealed mucus.** If Cleland over-
looked, or was unacquainted with the proposed operation of the
Versailles postpaaster, Wathan seems to have completely over-
looked the more recent and effectual discovery of Cleland; but in
allusion to the post-mortem examination to which I have just re-
ferred, he says, in the commencement of his very admirable essay :
^* As all these concurring circumstances strengthen me in my opi-
nion, they likewise incited me to make trial of an operation that
was some time ago proposed to the Academy of Sciences by M.
Guyot, but the author having never practised it, he wanted the
recommendation of facts to support and enforce it, it was, there-
fore, rejected by them as impracticable.** And in a note, he adds,
that Ghiyot having recommended the introduction of it through
the mouth, which is quite impossible, *' Petit proposed, and that
learned and skilful anatomist, Mr. John Douglas, first demonstra-
ted the possibility of passing the probe through the nose into the
Eustachian tube, and to him I freely acknowledge myself indebted
for the hint.** The catheter used by Mr. Wathan was not much
larger than a common-sized probe, and was bent a little at the
end, very nearly in the same form as that used by Kramer, the
distinguished Prussian aurist; and with this and a syringe he in-
jected and washed out the Eustachian tube and middle ear. There
can be no mistake about the mode of Wathan*s proceeding, for he
has given a very good representation of the operation in a plate
attached to his essay in the Philosophical Transactions.

I have dwelt thus long upon the introduction of instruments
into the Eustachian tube, as that operation formed the second,
and, perhaps, one of the greatest epochs in the history of this art,
because the merit is due to our own countrymen, and because the
English works upon aural surgery are not sufficiently explicit
upon this point, and many of the Continental ones are altogether

14 CAUSE AKD PBCULIAR1TT OF SHORT HEARING.

uninformed with regard to it,— Dr. Kramer, in his critical literary
review, being under the impression that Guyot had really intro-
duced the catheter through the mouth.

The essays of Cleland and Wathan, imperfect as they were,
were decidedly the greatest addition to aural surgery made in the
eighteenth century, and had the discoveries and valuable obser-
vations of these practical men been followed up in England, it is
probable we would now be far in advance of our Continental
neighbours. I would strongly recommend a perusal of Wathan*s
paper, as the cases he describes are most valuable in the diagno-
sis of obstruction of the Eustachian tube.

So early as 1842 I was familiar with, and have since frequently
pointed out to many of my medical friends and pupils a peculiar
form of deafness, in which the mcmbrani tympani had fallen in
towards the inner wall of the middle ear, — had lost much of its
vibratory power, and in which, wlien examined under a good light,
the handle of the malleus may be seen appearing to press outwards
in strong relief. In this affection, which, I have reason to believe,
is very often mistaken for nervous deafness, we have what may
be termed short hearing^ from an alteration in the vibratory mem-
brane of the car, in like manner as we have short riffhtedness^ or
myopia, sometimes arising from a peculiar alteration in the curve
of the cornea. I find, however, upon carefully perusing the pa*
per of Cleland, that he had some idea of what I have here de-
scribed, and of its being produced, as I have known it to be in
some cases, by accident. *' There is,"" he says, " another kind of
deafness, which proceeds from a violent clap of thimder, noise of
a cannon, or the like. In this case it is probable that the position
of the membrana tympani is altered, being forced inwards upon
the small bones, and so becomes concave outwardly. In this case
no vibration of sound will be communicated to the drum until the
membrane has recovered its natural position."*

During the remaining half of the eighteenth century I have
little to record ; the art does not appear to have advanced a single
step, either in Britain or any other part of Europe, Books and

* Philosophical Transactions, vol. xll. part ii. p. 850.

THS GERMAN AND FBENCH SCHOOLS. 15

essays were written, no doubt, but their authors added little to
the labours of their predecessors. The great majority of these
writings emanated from the German press, as, for instance, those
of Gniditsch, Wildberg, Milloradovics, Kritter, Amemann, and
Lentin. Of the French school may be mentioned Desmonceaux
and Leschevin ; the writings of the latter will be found in the
Memoirs of the Royal Academy of Surgery of Paris for 1763.
Having lately had occasion to examine this dissertation, which
was undoubtedly the best of its day, I am bound to say that the
lavish praise bestowed upon it by the French, and the severe
criticisms of the German writers, within the last few years, were
alike unmerited.

Up to the close of the eighteenth century no special work
upon the diseases of the ear had appeared in England, with the
exception of the translation of Du Vemey, to which I have
already alluded. English works have, it is true, been enumerated
by foreign writers, but they were not written upon the diseases,
properly so called, but on the congenital defects of the organs of
hearing. These I have specified in that portion of the work re*
lating to the instruction of the deaf and dumb.

In 1788 Dr. Peter Degravers, who styled* himself Professor of
Anatomy and Physiology, published in Edinburgh '' A Treatise
on the Human Ear,** as an Addenda to the second edition of his
^* Physico-Medical and Chirurgical Treatise on the Human Eye."
This tract consists of 62 pages, and is divided into three Parts: —
The Anatomical Exposition ; The Physiological Inquiry into the
Origin of Sounds ; and the external and internal Disorders of the
Ear. The work, though very much beneath that of the author^s
Observations on the Diseases and Operations of the Eye, is yet
intelligible enough, and came up fully to the state of knowledge
on aural surgery at that time. It is generally believed that Sir
Astley Cooper was the first person who perforated the membrana
tympani. Degravers, however, tells us in his essay that he com-
pletely removed the tympanal membrane in one case ; and again
he says : — *' I incised the membrana tympani of the right ear with
a sharp, long, but small lancet. I left the patient in that state for

16 SIMS AND THE LOKDOH MBDICAL 80CIBTT.

some time, and afterwards observed that it had re-united

I incised again the membrani tympani of the right ear but
eniciallj ; and on removing the parts of the membrane incised, I
discovered some of the ossicula, which I brought out."

During the eighteenth century the anatomy of the organ of
hearing was further studied by Valsalva, in his work ** De Auie
Humana Tractatus,** published at Bonn in 1704 ; and by I. F. Gas-
scbohm, whose book, ** Tractatus Quatuor Anatomici De Aure
Humana, Tribus Figurarum Tabulis lUustrati,** appeared in 1734.
These writings, with subsequently those of Scarpa, Soemmering,
and, in later times, of Arnold, have rendered the anatomy of the
organ of hearing very complete. Mr. T. Wharton Jones has embo-
died all that was known upon the subject when he wrote the arti-
cle ^' Organ of Hearing** in the Cyclopaedia of Anatomy in 1838.

The members of the Medical Society of London, instituted in
1773, and composed of the physicians, surgeons, and apothecaries
of that time, were not insensible to the low condition in which
aural medicine stood toward the end of the last century, and in
their valuable memoirs will be found some scattered notices upon
the diseases of the ear, from the pens of the president. Dr. Sims,
as well as from Mr. Houghton, Dr. Zeucker, a Prussian, and Dr.
Roslct of Ostend. Most of these papers contained post-mortem
examinations of cases of deafness, a practice that, with the ho-
nourable exception of Mr. Toynbee, has not, I regret to say, been
followed up, and very much to the detriment of aural medicine.
In Dr. Sims* essay he entered into a physiological discussion re-
garding the nature of the Eustachian tube, the object of which
was to show, that while we heard all external sounds through the
meatus cxternus, we were conscious of our own voice only through
the Eustachian tube. The practical part of his paper is, however,
exceedingly valuable, particularly with respect to the manner of
pressing air through the tube into the middle ear, by closing the
mouth and external nares, and then making a forced expiration;
but this had been already explained by Cleland in 1741.

In 1775 James Graham published in London " Thoughts on the
Present State of the Practice in Disorders of the Eye and Ear,"

QUACKS AHD QUACKSfiT. 17

8yo. ; and in 1780 J. EUliot made his ** Philosophical Observations
on the Senses of Vision and Hearing.^ Still, at the conclusion
of the last, and about the beginning of this century, aural sur-
gery and medicine were at a very low ebb, particularly in Great
Britain. This want of knowledge by the regular practitioner
upon the subject of diseases of the ear was, however, soon taken
advantage of, not only by professed quacks and nostrum-mongers,
but by the electrical, galvanic, and magnetic doctors of that day,
who corresponded to the homoeopaths, hydropaths, and mesme-
risers of the present. At the period to which I allude, galvanism,
magnetism, and electricity, together with the celebrated metaUie
tractors^ were applied to the ears of persons labouring under deaf*
ness, and numerous and wonderful were the cures vaunted in the
periodicals of the day, as having been effected by these remedies;
— cures almost equalling those lately said to be performed on the
eye by prussic acid : while secret, but never-failing acoustic drops,
stimulating embrocations, and the like impostures, were pawned
upon the public by all those who had ingenuity and effrontery
enough to make money after that fashion. And here let us for a
moment digress from the direct course of our subject to answer a
question that is often propounded — Why is it that the empiric
and the pretender, either licensed or unlicensed, — for in these
days there are as many and as impudent quacks with as without
diplomas, — why is it, one is ofl;en asked, that the charlatan fre-
quently succeeds in practice better than the honest practitioner?
By the term success, we do not mean professional success in his
arty but pecuniary success in life, and esteem among those with
whom money ''makes the man." Now although we cannot
alwajTS answer this query, nor would the same explanation be ap-
plicable to every instance, we can, however, assert one fact, which
in a great measure contributes to the success of the quack, and it
is this, — the hearty response of his patients to the lesson picked
up from the showman — ^^ speak a good word to your friends out-
ride." Let any well-educated, honest practitioner be called on to
treat an urgent and alarmingly dangerous case, where insidious
death stands at the sick man s door — let him bring all the power-
ful acquirements of long years of patient study and observation

18 QUACKS AVD QUACKBRT.

of disease — his anatomical and pathologrical knowledge-— an eye
practised to disease, and a head stored with the sound, rational,
scientific, practical principles of his art — let him add to this the
kindness of a friend, nay, often the benevolence of a bene&ctor— -
let him pass anxious days and sleepless nights watching each turn
of disease in his patient, and ministering to every of the many
wants that attend the bed of lingering sickness — let him do all
this, and finally (under Providence) restore the patient to health
and to his friends — stand, as we may say, between the living and
the dead, beckon back the approaching king of terrors, and give
again to society a valuable life, and to the trembling, anxious fii-
mily their only earthly means of support — what is his reward?
He is, generally at least, paid his fee, and the patient and his
friends are generous enough to say they feel grateful for all his
kind attention, for we will not curtail it of whatever good feel-
ing may be shown on the occasion. But compare this with a
patient who imagines he is cured of an imaginary disease by a
water doctor, or an atom doctor, an electro-biologist, a mesmeriser,
or a magnetiser, — is he not immediately converted into a partisan?
— does he not become a missionary for the nostrum-monger? —
does he not go about from house to house detailing the miracle of
his cure, the skill of the doctor, the horrors of the regular prac-
titioner, and the great benefit conferred upon mankind by being
converted into hydraulic machines; or expressing his surprise
that people will go about their ordinary business '* clothed and in
their right mind," like the man from whom the seven devils were
cast out, instead of being wrapped in a wet sheet, or enjoying a
sitz-bath for ten hours a day ; while others will wait upon you
specially, to beg and entreat you will not convert your poor
stomach into an apothecary's shop by taking all that '' doctor's
stuff," instead of procuring rest and ease to all your ills by just
such an anodyne as would be formed by pouring one drop of
laudanum into the Bosphorus, where it leaves the Euxine, and
drinking a thimble-full of the same water where it enters the
Mediterranean ! But, not content with this, these medical mia-
aionaries abuse all regular practitioners, and often force (for hu-
manity's sake, as they say) the charlatan upon the patient, who
then trusts to his address for future fame and profit.

CHBSS^BN AND COOPBB. 19

Iq 1793 Jaaser revived the old operation of perforation of the
mastoid process for the purpose of injecting the middle ear; but
as the success attending this procedure must be very doubtful,
and the hazard very great, it is never resorted to in the pre-
sent day.

Several experiments had been tried by anatomists and phy-
siologists upon dogs and other animals, in order to discover whe-
ther the function of hearing could be carried on with a perforate,
or imperfect membrana tympani. These investigations upon the
iower animals being deemed inconclusive, Mr. Cheselden, the
father of English surgery, proposed to experiment in this matter
upon the living human subject, and for this purpose a condemned
criminal was pardoned, on condition of submitting to the opera-
tion I but a popular outcry prevented its being put in force !*
Some years afterwards. Sir Everard Home, in his article upon
the muscularity of the membrana tympani, having expressed his
desire to know the result of perforation or destruction of this
membrane, Mr., afterwards Sir Astley, Cooper, published a letter
in the Philosophical Transactions for the year 1800, entitled^
'^ Observations on the Effects which take place from the Destruc-
tion of the Membrana Tympani of the Ear.** Although this
paper did not advance our practical knowledge upon the subject,
yet it called the attention of British surgeons to the treatment of
this important organ, and put an end to a very generally received
notion among the profession, that hearing would be totally lost
OB the opening of the membrana tympani ; notwithstanding that
a couple of hundred years ago it was believed by anatomists that
an aperture existed in this structure, as a normal condition dur-
ing life.

In the following year Cooper published an essay in the same
work on the perforation of the membrana tympani, as a means of
removing dea&iess caused by obstruction of the Eustachian tube,

* This case is referred to in Walpole*8 Reminisceiices, where it is stated that the cri-
nmud was Cheselden^s cousin, and that he was pardoned at the intercession of Ladj
Snflblk (ndstrees to George IT.), who, being herself deaf, wished to have the experiment
tried. The surgeon lost the royal fkyour, it is said, by the dicamstance. This story
auy, howerer, be but one of the petty scandals of the day.

c2

20 PKRFOBATION OI' THE MKMBRAHA TTJfPin.

and a consequent want of vibration in the tympanal membfine.
This paper commenced a new era, and opened up a wide field in
aural surgery. Like all discoveries in medicine, howeTer, it was
at the time, and in other hands, too frequently had recouiae tO|
and often misapplied. The brilliancy of this operation, and, in
some instances, its instantaneous effects, urged men to employ it
who were totally ignorant of its application, as well as of the
structures and diseases of the organs of hearing generally ; so that
it soon fell into disuse, and although recommended by this high
authority, the superior instruments we now possess of diagnosing
with greater accuracy the condition of the middle ear, and its in*
temal faucial aperture, by means of the air-douche, and also owing
to the comparatively few cases of deafness 9oldy depending on
closure or stricture of the Eustachian tube, have rendered its pei^
formancc much less frequently necessary than was at first sup-
posed. Hitnley, Itard, Deleau, Fabrigi, and others, improved and
modified the instruments and the operation of Cooper. This may
be termed the third epoch in our art; the two first being the ap-
plication of the speculum by Fabricius, and the introduction of
Eustachian cathcterism by Cleland.

I cannot conclude this notice of Sir Astley's improvement,
without quoting the pertinent and judicious remarks with which
he closes his memoir — advice and remarks which, I regret to add,
have been but little attended to, but which are as applicable to
the present time as they were to the period when they were written.

" I hope others will be induced," he says, in alluding to the
success of his operation, '' to second my feeble efforts, and to di-
rect their attention to a subject which appears to be of the highest
importance, and to have been too much neglected by medical
men ; for a knowledge of the structure of the ear is by no means
general in the profession, and still less are its diseases understood.
A prejudice has prevailed that the car is too delicate an organ to
be operated upon, or, as it is commonly expressed, tampered yn^\
and thousands have thus remained deaf for the rest of their lives,
who might have been restored to their hearing had proper assist*
ance been early applied.**

Not to burden the reader with too minute and extended a

SAUNDERS. 21

bibliology or critical review, I will now compress the history of
our art, with few exceptions, into the labours of British aurists.
The well-marked inflammatory diseases of parts of the auditory
apparatus, such as the auricle, external tube, and tympanum,
were generally treated, by all well-educated surgeons, as in the
present day, by strict antiphlogistic means, the local abstraction
of blood, purging, and counter-irritation ; but here the judicious
interference of art ceased ; and it would have been well if all fur-
ther meddling had been avoided; but laudanum was regarded
as a panacea in all cases of ear-ache, no matter from what cause it
may have arisen ; and drops, oils, and liniments, some of them
of the most caustic nature, were, without mercy and without dis-
crimination, poured into the external meatus by those, who like
the regicide of old —

" Stole
With jidoe of coned hebenon in a vial,
And in the porches of the ears did pour
The leperoos distilment.'*

first upon the list of British writers upon the acoustic appa-
ratus and its diseases stands John Cunningham Saunders, the
distinguished oculist, and the founder of the London Infirmary
for Diseases of the Eye, on whose merits, as an original observer,
a sound practical surgeon, and a critical anatomist, I need not
expatiate. His work, ^' The Anatomy of the Human Ear, illus-
trated by a series of engravings of the natural size ; with a Trea-
tise on the Diseases of that Organ, the Causes of Deafness, and
their proper Treatment,** was published in 1806, and although,
as I already said, he availed himself of the labours of Du Vemey,
still to Saunders we are indebted for the first special English
work of any merit upon this subject, and to him the various
charlatans that have ventured to set forward their ideas in print
are indebted for the mine from which they drew the material of
their various and voluminous publications. Saunders, as an
aorist^ has been unjustly dealt with : he wrote, not merely in ac-
cordance with, but beyond the knowledge of, his time, and
Kramer not only criticises his work with too great severity, but
denies it the place which, in a chronological point of view, it

SS CURTIS AVD HI8 FOIXOWKES.

deserves. This may, howerer, be sccoimted for by Kramei^s hav-
ing quoted from, as perhaps he only had access lo, the third edi«
tion, published in 1829, just nineteen years after Mr. Sanndas^
death. The practical portion of the work consisted of the history
and treatment of the diseases of the meatus extemus, and those
of the tympanum, of the obstruction of the Eustachian tube, and
of the diseases of the internal part of the ear, to which are added
cases of incipient nervous deafness successfully treated. The plates
are worthy of inspection, and were evidently drawn from recent
dissections. Saunders possessed, in addition to his originality,
honesty and general attainments in the science of anatomy and
surgery, this great requisite for an aurist^ — that, having also
applied himself to the study of diseases of the eye, he had thm
acquired habits of minute observation and delicate manipulation,
without which no man will ever attain to eminence in either
art. Moreover, the analogy which exists between the diseases,
as well as the anatomy and physiology of these two organs, ena-
bled him to bring to the study of the ear the rational principles
of medicine then established in the treatment of ocular affections.

For six or eight years we hear nothing of aural surgery in
Qre&t Britain, and our space will not permit of our even enume*
rating the names of the different Continental writers for the first
twentyjycars of the nineteenth century. Cooper*s more extended
and more lucrative line of practice caused him to relinquish aural
surgery, — this, and the untimely death of Saunders, seem to have
cast a veil over this branch of knowledge in these kingdoms.

In the years 1815 and 1817 we find two special works on an*
ral medicine ; of the first of these, ^* Dissertatio de Aure Humana SC
eju8 Morhis^^ an inaugural essay, published by Mr. Ball at Eldin*
burgh, there is little even to criticise; and the second was the
earliest work of the since far-famed John Harrison Curtis. Let
us read its high-sounding title : '* A Treatise on the Physiology
and Diseases of the Ear, containing a comparative view of iti
Structure, Functions, and of its various Diseases, arranged acoord-
ing to the Anatomy of the Organ, or as they affect the external^
the intermediate, and the internal Ear.** Let us draw from the
writings of a foreigner the opinion that a man of honesty and prad*

CU&TIS AKD HIS F0LL0WXB8. 23

tical experience formed of this and the author's subsequent works;.
'* Curtis,"* says the writer, <* treats every discharge from the ear
exclusiyely, and in a summary way, by means of astringents; ob*
struetions of the Eustachian tube, with emetics and perforation of
the membrana tympani ; whilst, in spite of all the entreaties of
Saissy , he has never once practised catheterism of the Eustachian
tube on the living subject. He makes tinnitus the chief symptom
of nervous deafness, which he treats with purgatives, especially
calomel, as long as the strength of the patient holds out.*' ^' In all
doubtful cases the chief attention is directed merely to ascertain
whether the liquor Cotunnii be partially or totally deficient ! ! or
whether hardened wax exist in the meatus."* ^* In the otitis of
children he sticks opium into the affected ear, &c., so that through-
out all his writings nothing but the most crude empiricism is to
be met with ; and yet among his compatriots, as well as abroad,
Curtis generally possesses the reputation of being a distinguished
aurist." And one of the first English medical periodicals of the
day thus expresses its admiration of the same person : ''Mr. Curtis,
in his Treatise on the Physiology and Pathology of the Ear, has
appropriated the whole of Mr. Saunders* essay. The exact words,
indeed, have, in some instances, been changed, but the plagiarism
is too manifest to escape even the most inattentive reader. To
this paraphrase of Mr. S.'s work, Mr. Curtis has added some
things from other authors, and some histories of cases treated by
himself (of course all most successfully), and has thus concocted
a treatise which, with singular effrontery, he has put forth as en*
tirely of his own composition, and as containing the results of his
own practice. This work has now, for a period of about twenty
years, been forced upon the attention of the public by the adver-
tisements of successive editions; and it is a melancholy fact, that
there should have been found editors of medical journals either
so ignorant or so careless as to lavish commendation on such a
production.**

Almost in a similar category may be classed the writings of
Williams, sumamed the nostrum-monger; and also those of Ste-
phenson and of Wright, " New Observations on the Diseases of
the Eye and Ear," 1817. The latter followed something of the
plan laid down by Curtis, of simply recomposing the words

24 THB WEITIHOS OF WmiQHT AMD WSBSTIB.

of his first work ; for as to new ideM, there were none, nor old
ones to add them to. In order to form either a new editioo, or
a new book, we find the changes rung to the following tones for
about ten or eleven years : '* An Essay on the Human Ear, its
Anatomical Structure, and Incidental ComplaintSi** 1819 ; ^ The
Aurist, or Medical Guide for the Deaf;** 1825; «« Plain Adviee
for all Classes of Deaf Persons, the Deaf and the Dumb, and those
having Diseases of the Ear,*" 1826, — verily, this must have been
a popular book ; " Observations on the Effects of Mercury on the
Organs of Hearing, and the improper use of it in cases of Ner-
vous Deafness,** 1827; "On the Varieties of Deafness and Dis-
eases of the Ear, with proposed Methods of relieving them,** 1829.
To these was added, *' The Present State of Aural Surgery,** to-
gether with three or four others, all by tlie redoubted Mr. Willing
Wright With these productions may be classed those of Wd>-
ster, Thornton, and Fletcher, works similar in substance and com-
position, although, perhaps, not so flagrant in plagiarism. Among
the writers of that period, and with some even down to the pre-
sent, it was usual to preface whatever they had to offer to public
notice as a euro for deafness by a lengthened description of the
structure and physiology of the ear, copied from some of the ge-
neral or special works upon anatomy. Thus, when one of the
persons just alluded to wished to advertise a new instrument, made
to fit the back of the auricle, for the purpose of collecting sound,
we find that there issued from the London press in 1836, *^ A
new and familiar Treatise on the Structure of the Ear and on
Deafness, by A. W. Webster, inventor of the Otaphone, &c. &cJ*
Among the illustrations to that work we observe an ill-executed
wood-cut, of a very ugly and misshapen auricle, but bearing the
attractive inscription of *' Mozart's Ear.** On perusing the text,
however, we discover that it was not the ear of the great musi-
cian, but that of his youngest son, ** which resembled that of his
father T One specimen from the medical portion of the book will
suffice: ''The membrane of the tympanum, which I have before
described as presenting the appearance of a large opal bead, was
frequently reduced^ both in size and colour, to the resemblance of
a mustard seed^ the burning substances which had been put wiikin
the ear having effected that change/'

HSPWOBTB AKB GARDNER. 25

But it was not alone among the instrument venders and itine-
rant aurists that ignorance and quackery were to be found. About
eight years ago I was sent a book, bearing the following title,
but without a date : " The Causes, Symptoms, and Treatment of
Nervous Deafness, Inflammation of the Eye, and Indigestion, po-
pularly treated by J. D. Hepworth, late Surgeon to the Leeds
General Eye and Ear Infirmary.** In the anatomical descrip-
tion he says, the membrana tympani is *' of a dry and brittle tis-
sue, without fibres or blood-vessels.** Nervous deafness is ascribed
to obstructions in the secretion of the fluid of the vestibule ; and
hardness of hearing, following measles or scarlet fever, to chronic
inflammation of the membrane of, and deposits of lymph within,
the semicircular canals ! Surely foreigners might well criticise
English writers on aural medicine when they read such state-
ments as the foregoing.

Somewhat of the same character is the work of Dr. Gardner
on Deafness, consisting of 152 pages, entirely devoted to the ana-
tomy of the ear, with half-a-page at the end explanatory of the
contents of the second part, upon the Pathology and Treatment of
Diseases of the Ear, but which we have not yet seen. This is the
only book upon the subject which has issued from the Dublin
press. It appeared in 1828.*

There is one English writer whom we would rescue from the
criticism which has been already applied to his predecessors. In
1823, Mr. Thomas Buchanan, an intelligent surgeon of Hull, pub-
lished an engraved representation of the anatomy of the human
ear, to which were added some surgical remarks on Eustachian
catheterism, together with an account of the operation of punctur*

* Its lengUiy and attractiTe title runs thoa : " A Treatifle on Deafiiets ; ita Canaes,
PieventioD, and Cure ; the Physiology and Anatomy of the Ear; the Uses of the difl^
not parts for the modification and conveying of Soonds to the seat of Hearing ; the dif-
ftnnt flsweo of Diseases incident to the different parts, and what class of Medicines are
best calcnlatffd to restore the several parts to their proper functions ; also, a representa-
tioo of the cases out of the reach of human aid. The map of the internal ear will diow
the precise situation of the most important parts, to fiudlitate the study of its anatomy, and
slioald be rsferred to in the perusal of this work. By T. Gardner, Esq., M. D., Aurist,
and Professor of Physiology of the Ear. Dublin : Printed by J. M'Mullen, 55, Ex-

isas."

26 BUOHAHAH.

ing the membrana tympani, and concluded with a tynaptioal ta-
ble of diBeases of the ear. Mr. Buchanan put forward many £»1-
lacies in hifl work, particularly with regard to the physiological
uses and diseases of the external meatus; and in a Uterary point
of view he seems to have fallen into the snare almost peculiar lo
English aurists, for within a couple of years he followed up wha^
ever success may have attended his first publication by producing
two other works, one, the " Illustrations," and the other, ** The
Guide to Acoustic Surgery ;" and in 1828 i^peared a fourth work,
*' Physiological Illustrations of the Organs of Hearing, more par^
ticularly of the secretion of cerumen, and its effects in rendering
Auditory Perception accurate and acute." Buchanan, however,
deserves our commendation and commands our respect as being
the first English writer who, since the days of Saunders and
Cooper, based his works upon a knowledge of the principles of
anatomy and surgery ; and to him we are indebted for an improve-
ment in the inspector auris, by means of which, as I have already
explained at page 12, artificial light may be transmitted through
the meatus to the membrana tympani.

About the year 1820 some notices of aural diseases appeared
in the medical periodicals, and foremost among the writers of these
stands Mr. Henry Earle, whose short, but accurate and practical
observations upon some diseases of the external meatus, published
in the London Medico-Ohirurgical Transactions, are well worthy
of perusal. The Lancet and Medical Grazette likewise contained
some detached notices, and the details and pathological appearw
ances of several cases of the diseases of the organs of hearing.

Within the last twenty years there have appeared three small
works upon the anatomy and physiology of the organ of hearing,
by Mr. Swan, Mr. David Tod, and Mr. Caswall. The first of
these, from the originality of its ideas, and the speculative theoiy
of its author, justly attracted attention in an anatoraico-physiolo-
gical point of view, yet neither it nor the other two with which
it is associated should have been enumerated in the history of au-
ral surgery, but that to each were affixed some observations upon
the pathology of the ear generally, and its congenital defects in
particular. These observations are, however, crude, speculative.

THB FBENCH SCHOOL. 27

and unpracticid. I may merely menUon one of thee^ as a siatn-
ple of the reat:-^Mr. Tod proposes as a remedy for congenital
deafness depending on derangement of the structures in the tym-
panum, the introduction of such acrid substances as ammonia,
oantharides, and the mineral acids, in order to produce such an
inflammation as may rouse into activity the dormant powers of the
parts contained within that cavity I

The splendid discoveries of Laennec with regard to the ste-
thosoope, and the morbid or abnormal sounds produced by streams
of air passing over diseased structures, were not long in being
employed as a means of diagnosis by such of his countrymen
as had devoted their talents and energies to the investigation
and treatment of diseases of the ear. Foremost among these stood
Deleau,* whose works first established the more general prac-
tice in Europe of the introduction of various medicated vapours,
as well as fluid injections, into the middle ear, by means of cathe^
terism of the Eustachian tube, a mode of treatment since so ex-
tensively employed by Kramer. But it should not be forgotten
that similar means were used in England nearly a hundred years
before by Cleland and Wathan. The labours of Itard are also
Worthy of attention, from the clearness and perspicuity of his
views, and firom his vast experience in ti^ating the inflammatory
diseases of the external and middle ears, yet his work is by no ^
means devoid of those prejudices which, even to the present day,
like the amulets of a by-past age, still hang round books upon
aural surgery .f

To these may be added the works ofM. E. Hubert Vallerouxi
the chief of which is the '* Eiaai Theorique et Pratique wr les
Maladies derOreOUr Paris: 1846.

We now turn again to Germany, where we find aural surgery
in a higher condition than in any other country in Europe. To
enumerate all the books and pamphlets on diseases of the ear

• " Becherdies Pratiqiie sor les MalAdies de rOi«ill«, et lur 1e DeveUoppement d«
rOreille et de la parole chez les Surds Muets.** Paris : 188S.

t**TriiledC0 Maladies deUOreilleetder Audition.'* Tom. iL Paris. Second edi-
tioD,lS42.

28 THB GBRMAH tCHOOL.

which had emanated from the Gtennan pieas ainoe 1830 would
occupy unneceaaary space in this limited outline, but the princi-
pal were the writings of Kramer, Lincke, Schmalz, and Frank.
Dr. W. Kramer, of Berlin, published his first work, An Easay
on Chronic Deafness, in 1832, and thb he afterwards enlarged
and published as a System of Aurat Surgery in 1836, ** Die JBt-
kenntniss und Heilunff der OhrefJcrankheUmJ^ In the following
year it was admirably translated into English by Dr. J. R. Ben-
nett, and is decidedly the best special treatise on the subject
which has yet appeared in this country, where it exercised a
most salutary influence upon the diagnosis and treatment of dis-
eases of the ear. *' In these and other signs," writes the reviewer
of Dr. Bennett*8 translation in the British and Foreign Medical
Review for 1848, '' we think we see clear indications of a new
era in acoustic (?) surgery in thb country, when learning aifd
science shall assert their rights, and the despicable ignorance and
impudent empiricism which have hitherto prevailed shall be le-
duced to their proper level.*** The truth of this prediction has
since been verified. Dr. Kramer subsequently published two
other works upon the ear, — ** Beilrdge zur Ohrenheiikunde^ in
1845, the major part of which relates to the statistics of aund
diseases, — to which I shall have occasion to refer in the next chap>
ter,— and '« Die Ohrenheilkunde in den Jahren 1849 und 1850.*
Independent of the luminous descriptions, the critical acumen,
and practical observations, and the consequent absence of quack«
ery, with which all Dr. Kramer's writings abound, the chief new-
ness and originality of the work, which has been translated into
our language, consisted in the details of cases of nervous deafness,
so called, said to have been cured by the introduction of etherous
vapour and other gaseous substances, by means of an air-pump,
into the middle car, though the Eustachian tube. By thus fumi-
gating the mucous membrane lining the drum, it was said that
the dormant powers of the auditory nerve were stimulated to a
healthy action I As a means of diagnosis the instrument is very

* In Uie adminble periodical from which the above has been extracted wiU be Iboad
■everalleanMd artidea on aoral medicine.

THB WRITINGS OF KBAMEB. 29

valuable, although the cases in which it is required are compara-
tively few ; but as a therapeutic agent the Eustachian pump has
been much overrated, and if* benefit to any extent has been de-
rived from introducing medicated vapours into the middle ear, it
is more than probable that the deafness was in such cases caused
by inflammation of the cavity, upon the investing membrane of
which those minute ramifications of the tympanic plexus of the
glofiso-pharyngeal nerve are distributed, as had been previously
remarked by Mr. Swan. Ten years' trial and experience has not,
in other hands at least, verified the anticipations which were en-
tertained from a perusal of the Berlinese aurist's opinions. The
rage for fumigating ears, as well as eyes, has for the present passed
by. It has not been found that the vapour of ether cures cases of
paralysis or impairment of the function of the auditory nerves, no
more than the fumes of prussic acid afford relief in amaurosis, or
remove cataracts or deep-seated corneal opacities. A new and
enlarged edition of Dr. Kramer's book on the Nature and Treat-
ment of Diseases of the Ear appeared in February, 1849, the
author having been, he says, induced, during the revolution in
the Prussian capital, to betake himself to literature and the revi-
sion of his former writings. From the tone of the remarks which
have been introduced into this new edition, one is inclined to
think the writer's labours must have been very much interrupted
by the fierce battie waging around him ; for certainly while we
are unable to discover much additional matter of value therein,
we are not a little surprised at the style of his language, so un-
courteous, and imsuited to a scientific subject. For myself I cannot
but feel complimented by having so large a portion of the inser-
tions in the new edition of this work devoted to the consideration
and review of my writings and opinions ; but for the sake of lite-
rature and science, and the friendly feeling which has so long
existed between the Irish and German schools of Medicine, I
cannot but regret that my friend did not discuss the questions at
issue in a calmer and more philosophic mood.

Dr. C. 6. Lincke, of Leipzig, has published a voluminous
work upon Ear Medicine, consisting of two volumes, the first of
which, upon the Anatomy, Physiology, and Pathology of the Or-

30 THE WORKS OF UHCKB, 80H1UI.I, AJTD FRAmL

gans of Hearing, appeared in 1837 ; and the 8eo(md« on the Mo-
aology and Therapeutics of Diaeaaes of the Ear, was brooghl om
in 1840. This '' ffandbuch der T/^earetischm und PrakiUeken
0/trenheilkund6j^ not having been translated into the language of
this country, is not as well known as it deserves; for although it
does not contain much original matter, is rather prolix in its lite-
rary analysis, and is, perhaps, somewhat too minute, not to say
fanciful, in its division and enumeration of diseases of the ear,
yet it comprises all that was known upon the subject of aoial
surgery at the time it was written, and is most valuable as a work
of reference, exhibiting great learning and research.

Another industrious compiler is Dr. E. Schmala, of Dresden,
who has written several useful treatises upon this subject, and
whose work upon deaf-dumbness, ^' Kuee Gesehiehie wmd Star
tittik der TaiAsitimmenafuiaUen und da Taub&tummamiinierriekim
nebet vorausgeiehiekten arztliehen JBemerkungen uber die Tmfh
stummkeiit'' was one of the best when it appeared in 1830. The
other principal works of this author are his *' Effahnmgen uber
die Krankkeiten des Gehores und xkreHeilung^ published in 1846,
and '* Beitrage eur Gekor-und SprackrHeilkunde^^ in 1848.

Dr. Martell Frank, of Wiirtzburg, issued in 1845 his "Pfo^
Hiche AnleUung zur JErkermtnisi und Behandlung der OAroi-
krankheUen^ &c., an admirable digest of the subject, abounding
in references, but not containing much original matter. Like the
works of the two former authors, it will be principally useful as a
work of reference ; and it abounds in wood-cuts, illustrating the
different instruments used in aural surgery.

I shall now conclude this review with some notices of modon
English writers. In 1837 the Medical Society of London offered
a prize for the best essay on ** The Structure, Economy, and
Diseases of the Ear." This, together with the Fothergillian Me-
dal, was awarded to Mr. Pilcher of London, who in the following
year published his essay as ** A Treatise on the Structure, Eco-
nomy, and Diseases of the Ear.** It is divided into three parts : the
Anatomy and Physiology, the Abnormal Conditions and Malfor-
mations, and the Diseases; the latter consisting of 171 pages;
a truly practical work, divested of all those absurdities which,

THE MODBBH ENGLISH SCHOOL — PILCHEB. 31

wilh the exception of those of Saunders and Buchanan, charac-
terized its predecessors in the British metropolis. The profession
would, I am sure, in the subsequent editions of this work, rather
■ee the author^s opinions supported, and his descriptions illustrated,
by cases occurring under his own observation, of which he must
have many, than those supplied by his friends, or extracted from
periodicals. If Kramer led the profession to expect too much
from the use of the air-pump, and the introduction of medicated
vapour, I cannot but think Mr. Pilcher's practice of washing out
the middle ear by means of a syringe attached to a catheter passed
through the Eustachian tube is, to say the least of it, unneces-
sary ; and his method of exploring that passage and the tympa-
num, by introducing whalebone sounds and silver stylettes, is
rather heroic. The author says : '' The surgeon must be specially
eareful not to injure the^ssicula, the avoidance of which will re-
quire great caution, passing as they do across the cavity ; the
•ftylette must, therefore, ju^ reach the tympanum, without enter-
ing it;** but we are not informed by what tactua eruditus this is
tShcted. Mr. Pilcher*s treatise is illustrated in both the anatomi-
cal and pathological departments ; but not in accordance with the
•tate of art in Great Britain fourteen years ago ; of which the
relation, size, shape, and bearing of the Eustachian tube and
meatus auditorius externus, in Plate IX. fig. 1, is an example*
It is very difficult to have a faithful drawing made of die appear-
ance of the membrana tympani in disease ; in fact the artist re-
quires to be well acquainted with aural pathology before he can
be perfectly successful ; and therefore this defect — which has
not as yet been remedied — is one of the causes which retard the
progress of aural medicine. It is therefore of great importance
that the appearance of the external surface of the membrana
tympani, which, from its concealed position, very few persons
ever see, should be well described, both in a healthy and diseased
state, and all the peculiarities of the former accurately recorded.
One, consequently, regrets that Mr. Pilcher did not record the
ordinary appearances of this structure, as seen with a stream of
well-directed sunlight upon it, when describing its anatomical
lela^ns and connexions ; in one point of which latter I must

32 WHXIAMS AMD T. WHABTOH J0R8.

differ with him, and thb point it is necessary to allude to^ because
it really is of practical importance to those commencing the study
of aural diseases, and having, perhaps, to observe for themaelveSf
without the benefit of clinical instruction, to know, that in the
usual erect position of the human subject, the manubrium of the
malleus, which is the chief object on which the eye first rests in
examining the ear, is twt ''inclined a little forwards, but par-
ticularly inwards,** but proceeds downwards and backwards. As
it is not intended to discuss the opinions of authors at any length
in the practical and descriptive portions of this work, these ob-
servations will not, I trust, be deemed inappropriate here.

In 1840 Dr. J.Williams published a '< Treatise on the Ear;
including its Anatomy, Physiology, and Pathology ;** which was
originally written as an Inaugural Dissertation at Edinburgh, and
for which a gold medal was awarded the author by the Senatus
Academicus of that University. It is a valuable and unassuming
compilation, well *' got up," and with good engravings, but it has
not added much to our stock of knowledge on the subject, and is
more valuable as a book of reference than a practitioner*s guide
or student's manual. Cooper's Surgical Dictionary, especially
the seventh edition, published in 1848, also contains much curious
information, and quotes many remaikable cases bearing upon
aural surgery.

In the ninth Part of the Cyclopedia of Practical Surgery,
published in 1841, Mr. T. Wharton Jones wrote the article^
'* Ear and Hearing, Diseases of.** This essay was, as might be
expected from the character and talents of its author, by far the
best resume of the subject which had appeared in British print, —
highly learned, and at the same time in many respects practicaL
Mr. Jones commences with an introduction upon the analogy
which exists between the anatomy and pathology of the organs of
sight and hearing, which we should like to have found carried on,
as we believe it might be, through the entire essay, the more es-
pecially as from the author's education and peculiar acquirements
it is probable that it could have been done with greater advantage
by him than by any other writer. He is an advocate for Eusti^
chian catheteriem and the use of vaporous injections, to a greater

T. WHARTON JONS8*8 ESSAT IN CYCLOPJEBIA OF SUSOERT. 33

extent than yrill, I believe, be found hereafter necessary. He has,
moreover, introduced into this article the minute details and
daily records of cases, occupying ten pages, which is rather an
unusual proceeding in Cyclopaedia writings, and more in accord-
ance with the state of medical literature thirty years ago than at
the time it was written. It would partake more of the nature of
a review than a literary analysis, were I to enter upon a length-
ened criticism of these cases, but their perusal will, I think, con*
Yince the reader of their inapplicability to the place where they
are inserted. One case, the first recorded by the author, is worthy
of note. A female complained of deafness accompanied by tin-
nitus, the consequence of a cold. The external auditory passages
were impacted with hardened wax. On the left side the hearing
distance by a watch was but two inches. Upon the wax being
removed by syringing, the hearing distance was increased to '^ fif-
teen feet four indiea^! and the tinnitus entirely removed. The
membrana tympani is said to have been ** opaque, and slightly
yellow ;** but the report does not state whether the patient could
herself inflate the cavity of the drum. A solution of acetate of
lead was poured into the auditory passages two or three times a
day. For some days the hearing distance varied; a catheter wasf
then introduced, and the air-douche applied. Upon the third ap-
plication the air penetrated the tympanum freely, and the hear-
ing distance was then increased to nineteen feet nine inches ; but
the report does not say what it was previous to the application
of the douche. There are few persons who have ever experienced
the stuffing and annoyance consequent upon **• a cold in the
head," or any swelling or irritation of the mucous membrane of
the fauces, throat, and nose, who have not experienced sensations
and variations in hearing similar to those recorded in the case re-
lated in the Cyclopsedia of Surgery, but who have generally cured
themselves by blowing the nose, sneezing, or coughing. More-
over, when wax has been a long time impacted in the auditory
passage, it often presses the tympanal membrane inwards, and the
patient does not quite recover the hearing, or get rid of the tin*
nitos, for some days after the removal of the cerumen, or until a

D

34 T1AE8LBT'8 PUBUCATI0II6.

forced cxpimtion presses the membrane outwards into its natmal
position.

During the last fourteen years Mr. Yearsley, of London, has
published several works (and issued several editions of each) in
connexion with diseases of the ear. The first of these was Parti.
of ** Contributions to Aural Surgery,"* consisting of the Proceed*
ings of the meetings of the committee for managing *< The Insti*
tution for curing Diseases of the Ear,** to which was added a
Medical Report, and also the detailed account of cases. The
earliest of these tracts appeared in 1839, and the third, which is
the last I have seen, in 1841. They abound in copious extracts
from various authors, and in particular from the then recently
translated work of Kramer. In these publications the author
chiefly labours to impress upon the profession and the public the
necessity of Eustachian catheterism in all diseases of the ear. In
1842 Mr. Yearsley published '^ A Treatise on the Enlarged Ton*
ul and Elongated Uvula, in connexion with Defects of Voice,
Speech, and Hearing, (ftc.,*" of which several editions have since
appeared. The author recommends excision of the tonsils for the
cure of deafness, and we believe a great number of persons have
since submitted to the operation ; with what degree of success the
profession in London arc the best judges. Every practical phy*
sician and surgeon must be well aware that enlarged tonsils do
not of necessity produce deafness; I shall, however* leave the
further discussion of that subject to the work of Mr. Harvey, to
be noticed presently. In 1847 there appeared by the same au*
thor, ** Deafness practically illustrated, being an Exposition of
Original Views as to the Causes and Treatment of Diseases of the
Ear.'' These original views consisted of a reprint, with scarcely
an alteration, of the three original tracts originally published, from
1838 to 1841, and a large portion of the book upon the Throat
just referred to, to which were added chapters upon *' Stomach
Deafness ;'' the Statistics of Deafness ; on the best means of com-
pensating for Incurable Deafness ; and on Ear Trumpets. The
author's description of stomach deafness is as follows: — *' The so-
called nervous deafness, hitherto a stumbling-block to contempo-

TBAB8LBT, DUFTON, AND HABVBT. 35

raiy writers, is nothing else than an injurious influence exerted
on the ear by dyspeptic ailments, though commonly pronounced
a disease depending primarily on the auditory nerve itself." And
again : — ** The first description of deafness from digestive disorder
is that in which the disease is strictly confined to the stomach, no
perceptible change having occurred in the organ of hearing, ex-
cept functional torpor of the auditory nerve. This is best seen in
acute indigestion.** Obstruction of the biliary secretion, accumu-
lation of morbid bile in the gall ducts, and chronic dyspepsia, are
the other abdominal derangements supposed by the author to
produce deafness, which he believes to be caused by an extension
of a sub-inflammatory condition of the mucous membrane into
the throat, and thence into the cavity of the ear, and even to the
external meatus ! To Mr. Yearsley, however, is due the credit
of having first drawn the attention of the profession to the very
valuable remedy of introducing a portion of moist cotton into the
external meatus in oases of deafness arising from perforation of
the tympanal membrane. The original communication upon this
subject was published in '' The Lancet** for July, 1848, and was
afterwards reprinted as a tract upon '^ A New Mode of treating
Deafness when attended by a partial or entire Loss of the Mem-*
brana Tympani, associated or not with Discharge from the Ear.**
This question will be again considered in the practical portion of
this work devoted to Otorrhcea.

Li 1844 Mr. W. Dufton, of Birmingham, published a little
work, entitled ^^ The Nature and Treatment of Deafness and Dis-
eases of the Ear, and of the Treatment of the Deaf and Dumb.**
And in 1847 Dr. J. W. Moses, of St. Asaph, wrote a short
*^ Treatise on the Human Ear, with new Views of the Physiology
of the Tjrmpanum.**

Mr. W. Harvey, of London, has written some papers on Au-
ral Sultry in the periodicals, and published a Chart of Diseases
of the Ear, of which he issued, in connexion with Mr. Thomas
Buchanan, of Hull, — to whose works I have already alluded at
page 25, — a second edition in 1848, entitled *' A New and Im-
[MToved Synoptical Table of the Diseases of the Human Ear, with
tfieir Symptoms, Causes, and Treatment.** Simplicity of nomen«

d2

36 HARTET.

claturc characterizes most modem medical writings, at least in
Great Britain, and to this end the labours of Mr. Farr, in his
various publications upon Vital Statistics have tended in no small
degree. One can therefore scarcely appreciate the advantage de-
rivable from any classification abounding in terms like the follow*
lowing: — akoluthise, dermatine, anachrosis, ptoeees, kerinadids^
sunakolouthesis, derringitis, apoplanesis, laburinthitis, stereas,
skleragosis, &c. &c. In 1850 Mr. Harvey published a book
'' On Excision of the Enlarged Tonsil, and its Consequences in
cases of Deafness, with Remarks on Diseases of the Throat**
In this most useful work the author has fairly established the
fact that removal of the tonsils docs not cure dea&ess, and thai, in^
dependent of any risk in the operation itself, the excision of these
bodies is oflen attended with subsequent unpleasant results to the
patients. Every author who writes on any subject connected
with diseases of the ear thinks it necessary to conclude his work
with a chapter on deaf-dumbness, although very few modem
writers have added anything to our stock of knowledge as regards
the statistics, medical treatment, moral management, or pathology
of that affection, because very few practitioners have any expe-
rience of such matters. The following paragraph upon this sub-
ject, from Mr. Harvey's work, is an example : — '* A deaf-mule
can learn to read and specJe perfet^y^ without hearing a sin-
gle tone ; so that the only true test of a deaf-mute is his being
able to converse with a stranger as well toithout the aid ofkU ey$i
as any person who hears well is daily in the habit of doing.** —
page 104. Now in the English and American schools, and most
of those on the Continent, all attempts to make the deaf and dumb
articulate have of late years been relinquished ; and how the deaf*
mute is able to converse with a stranger without the aid of his
eyes, one is at a loss to discover. Mr. Harvey promises to trans-
late and annotate the work of Lincke referred to at page 29, and
also to afford us a book on certain rheumatic diseases of the ear.

Among the writings bearing on this subject may be mentioned
the interesting work of the Rev. Dr. Kitto on *^ The Lost Senses —
Series I. Deafness,** published in 1845, in which the feelings, sen-
sations, and impressions of the author, himself the subject, as he

TOYNBEE*S RESEARCHES. 37

states, of ** the most intense deafness to which any living creature
can be subjected,** are graphically and feelingly described.

The labours and investigations of Mr. Toynbee have effected
more for aural pathology than those of all his predecessors either
in England or on the Continent. He commenced at the right
end, and has travelled in the proper direction. He has brought
t6 bear upon the subject the true principles of science, and with
the assistance of the microscope, — the aid of every modem artistic
appliance to assist him, — accustomed to habits of minute dissec*
tion, patient research, and careful observation, — he has accumulated
a mass of facts upon the morbid anatomy of the organs of hearing
that must lay the foundation for a more rational mode of treating
the diseases of those parts than has heretofore been resorted to.
Mr. Toynbee has already recorded the results of the dissection of
the ears of about 750 persons sent to him for examination, but
of which number not more than sixty or seventy were from per«
sons the history of whose deafness was known.

Mr. Toynbee has laboured extensively, and with effect, to
discover and describe the post-mortem appearances which disease
has produced in the organ of hearing ; and I trust he will long
continue to prosecute, with the same avidity, the same honesty of
purpose, and an equal amount of critical acumen, his valuable re-
searches. Morbid anatomy, however, is one thing — pathology
another. The dead subject upon the dissecting-table teaches the
student not disease, but the results of disease. It avails little that
the hospital pupil should have pointed out to him, in the dead-
room, the violence which sudden accidents may have caused, or
the ravages which slow disease has produced in the various organs
or textures of the body ; it matters not to what extent the micro-
scope may exhibit the wide-spread lesion, or chemical tests dis-
close morbid products, unless the cases have been observed during
life,- and the progress of disease previously noted at the bedside.
Therefore it is that the School of Vienna, — where a dozen bodies
from different parts of the Great Hospital, but the histories of
which are unknown, are sometimes cut up, and their post-mortem
appearances displayed in the lecture-room on a morning, — may,
under the able teaching of Rokitansky, Engel, and others, teach

38 THX OLTCXEUIB CURB.

morbid anatomy, (pathology ao called), but does not prodnoe
many practical physicians.

Mr. Toynbee*8 researches prove the pontioa which I long ago
advanced, and which from year to year I have been in the habit»
not only of teaching theoretically, but practically demonstrating
in my clinical lectures, — that the great majority of diseases of the
ear producing deafness have their origin in inflammations of one
kind or another. Every day's experience confirms me in this
opinion ; and the cases which I now publish will, I think, oorro-
borate that view of the subject. Mr. Toynbee has not jret pub-
lished any separate work upon the ear, but has contributed his
observations on the Anatomy, Pathology, and Treatment of the
Organs of Hearing to the different societies, and also to the
periodicals, of London. Among the latter may be mentioned
chiefly, the Philosophical and Medico-Chirurgical Transactions,
from 1843 until the present date. He has also written several
valuable papers in the Medical Times, Lancet, Provincial Jour-
nal, and Edinburgh Medical Journal.

Subsequent to Mr. Yearsley's recommendation, a fluid called
glycerine was recommended, on account of its inevaporability,— >
a property which it undoubtedly possesses more than most other
liquids, — as the only proper substance with which to moisten the
wool or cotton introduced into the meatus in cases of perforate
membrana tympani ; and from being employed with effect in one
set of cases, its virtues were vaunted as a cure for all, and during
the last few years we hear this medicine extolled in the public
newspapers, as well as the medical periodicals, as a panacea for
deafness of all kinds, and arising from all causes. The virtues of
glycerine were first made known to the profession through Mr.
T. Wakley, who published an account of it in the Lanoet ia
1849. Since then glycerine has had ^* a run,'' particularly among
the members of the profession not specially engaged in the tieat*
ment of aural diseases ; and we may, therefore, well imagine in
what a variety of cases, arinng from the most opposite causeti
and presenting a totally different set of symptoms, this remedy
has been applied. Cases of nervous deafness of long standing,
thickening and opacity of the membrana tympani, inflammation

WAKLBY. 39

and mucous engorgement of the cavity of the tympanum, thick-
ening of the cuticular lining of the meatus resulting from otor-
rhoea, the yarious inflammatory affections of the ear, as well as
simple impaction of the meatus with cerumen, are constantly for-
warded to me by practitioners with the following note : — '' We
have applied the glycerine, as lately recommended for the cure of
dea/neaSf for some weeks past; but the patient not having expe-
rienced reUef, we wish to have your opinion," &c. When the
case does not turn out favourably, it is said by its supporters that
the remedial agent is not pure ; and when its purity has been
tested and proved, then it turns out that the remedy was inappli-
cable to that particular case. Like all other remedies proposed
for deafness, it has been misapplied, and even the original inten-
tion of its inventor lost sight of. The cases to which it is said to
be most applicable are those of defective cerumen, dryness of the
Auditory passage, thickening of the membrana tympani, and that
peculiar condition of the epithelial lining of the external conduit
which results from previous otorrhoea. Deficiency of cerumen is
but a symptom contingent upon other diseases ; it is not of itself
a disease of the ear nor a cause of deafness ; and no better proof
of this can be offered than that instanced by a case of defective
hearing caused by accumulation of hardened wax. The patient
is totally deaf, and labours under tinnitus aurium and other
symptoms consequent upon such mechanical obstructions, which
are well kno¥m to every practitioner. The application of a jet
of warm water, properly directed, removes the hardened wax,
when the bearing is instantaneously restored, nay, often consider-
ably exalted. In a few hours the meatus becomes perfectly dry.
Why then is it that the hearing remains perfect, although the ce-
rumen has been completely washed away ? Again, as to dryness
and paleness of the meatus, it should be remembered that such is,
with the exception of the part coated by cerumen, its natural
condition. As regards thickening and opacity of the tympanal
membrane, if glycerine can remove such, either by maceration,
any caustic property which it may possess, or by inducing ab-
sorption, then indeed will it be found a great boon. In cases of
thickening of the Uning membrane of the meatus, and a dry,

40 WAKLET OH GLYCS&IHE.

scaly condition of the epithelium, npon the drying up of a muco-
purulent discharge, it ia of importance to restore these parts to a
healthy condition by remedial agents, of which glycerine is not
the best nor the only one. There are, however, cases in which
benefit will be derived from preserving the meatus and external
layer of the membrana tympani moist. The effect of such mois-
ture is well known, not only to aural surgeons, but to patient!
themselves, who arc in the habit of applying a little oil or even
water upon the point of the finger to the external meatus when-
ever they find their hearing particularly defective; and in such
cases tiiis remedy, from its remarkable property of remaining
fluid, when most other liquids evaporate, will be found useful
Such cases, however, arc comparatively rare.

The substance denominated glycerine was discovered by
Scheele, and was afterwards investigated by Chevreul. It is an
almost inodorous, syrupy fluid, which gives a peculiar smoothness
to the part on which it is rubbed, and is obtained in the making of
litharge plaster, by washing that substance, and passing sulphu-
retted hydrogen gas through the washings to remove the lead, —
afterwards filtering and evaporating. It is soluble in water and
alcohol ; does not dry or evaporate at the ordinary temperatuiei
but if boiled, it partly distils and partly decomposes, acroleine
being among its products, — and it is not liable to ferment. It is
found in combination with most oils, except that obtained from
the liver of the cod, now in such extensive use, which Winder
has ascertained does not contain it. Time, and the experience
of the profession, which test all such remedies, no matter how
vaunted or how popular, will, no doubt, develop the therapeu*
tical effects of this substance in diseases of the ear, if such it pos->
sesses, beyond those which I have already stated. Its powers are
already beginning to be questioned ; — a book has, however, been
written on the subject, — the last in connexion with diseases of
the ear which has appeared in Great Britain, — and in accordance
with the principles of this chapter it must be referred to.

In 1851 there appeared '* Clinical Reports on the Use of Gly-
cerine in the Treatment of certain Forms of Deafiiess, by T.
Wakley, F. R. C. S. Edited by W. Tindal Robertson." Any

WAKLBT ON QLTCEBINE. 41

proposition to relieve so serious and so widely-spread an infirmity
as dea&ess, emanating from a legalized practitioner, should be
hailed by the profession as a benefit conferred upon science and
humanity ; but at the same time it behoves the propounders of
such cures to show that their cases are well worthy of credence,
and that their descriptions of disease, details of symptoms, diag-
nosis, and prognosis, are in accordance with the present state of
medical science bearing upon such affections. Now, I do not
think this work is in that position. For the application of gly-
cerine the author recommends an instrument resembling a porte-
crayon, for holding a piece of cotton saturated with the new
remedy. The external meatus being washed out with tepid
water, and thoroughly dried, which appears to be a necessary
preliminary, we are gravely informed that the cotton '* should be
80 fixed that in moving the instrument to and fro in the external
meatus, the free passage of air should be provided for, otherwise
an imperforate tympanum might be ruptured" ! ! The book con-
tains the record of twenty-eight cases, in the majority of which
the streets, but not the numbers, in which the patients lived, are
given. The hearing distance before the application of the re-
medy is not stated, although the author has, he states, invented an
instrument, which he styles a Sonometer, for the purpose of mea-
suring the hearing distance, and which, he says, ^' has proved of
the greatest value in practice,** and *' has done service to the pro-
fession." But what that value, and what that service is, beyond
what may be acquired by an ordinary loud-ticking watch, is not
recorded.^ In reading over these cases, when we find such state-
ments as the following, we are inclined to think that their re-
porter— we suppose some pupil of Mr. Wakley's — was not very
conversant with either the normal or pathological appearances of
the human ear: — " The tympanum of each ear was sound.** —
•* The tympanum of each ear was perfect.** — " Care having been
taken to apply it to the tympanum.** We suppose the reporter
alluded to the membrana tympani. Again we read : *' When the

* I Mw a timiUur instniment uaed by Dr. Schmalz in Dreaden in 1840. He claimed
the inveoUoo of it, and has described it in his various writings.

42 OLTGBEUIB U DBJlV-DUMBVBBS.

ears are under the influence of glycerine.** — ^* The meatus of each
ear is exceedingly hard.** — ** Of a very pale colour.** — ** The aural
passage and tympanum [jjuere middle ear] exhibited a white, po-
lished appearance,** &c. Among the cases related is that of a boy,
deaf and dumb, in which the author says: — '< The ears are Tery
small.** We then hear that " the ears were well mOurated with
glycenne,** and the hearing distance tested, when, marvelloufl lo
relate, the boy seemed ^' to signify with his fingers the number of
times he was called by his father.** ** It is evident,** says the au-
thor, in concluding the report of this case, ** that he received a
certain amount of benefit firom the glycerine.** Here now ia a &ir
case: — E. M., Dean-street, London, a deaf-mute, who ia said to
have derived benefit from this remedy. Let the boy be produced
to the profession, and to the instructors of the deaf and dumb,
and let them decide upon the amount of benefit derived from this
or any other remedial agent in curing a case of true muteiam.
These cases, however, in which even '* a certain amount of bene-
fit** is said to have been derived from treatment of any kind by
an unhappy deaf-mute, have their efiect upon the public mind, as
was instanced some years ago in the TumbuU cures related in
Chambers's Journal, to be referred to presently.

In a second section of this book, consisting of a clinical lec-
ture on the use of glycerine, illustrated by eleven cases, in which
the remedy is most advisable, we find that four were instances of
simple impaction of wax, which might have been removed in a
few minutes by some warm water and a syringe. In the fiiit
portion of the work, dry cotton is the substance recommended for
the application of the glycerine ; in the latter section, howeverp
at p. 64, sheep's wool is that deemed most advisable by the author.
I have already alluded at p. 3 of this chapter to the old Irish re-
medy, which partakes more of the nature of a superstition than a
therapeutic agent of a cure for deafness, in a bit of wool, taken at
a particular time, and under particular circumstances, from the
left fore-leg of a six years old black ram. In the metropolis of
the world, during the middle of the nineteenth century, with sci-
ence, philosophy, and common sense influencing the actions of
mankind to the extent which at present prevails, one did not ex-

TUEHBUIX. 43

pect to find the aurgeon of a London hospital recommending as a
portion of the new cure for deafness, '* the finest curled wool on
the sheep's heady carefully cut with scissors, and washed in hot
water," and adding, '^ the best wool is that procured from a small
German sheep f age unspecified.

I have dwelt thus long upon the present popular cure for
deafiiess, and endeavoured to expose its fallacy, in the hope that
the eyes of the profession may be opened to the ine£Scacy of such
modes of treatment, and that our continental neighbours may not
have an opportunity again of writing such critical reviews of Bri*
tish authors as those which formed an introduction to Dr. Kra*
mer^s book.

Well-educated surgeons and honest men have at last come
forward to rescue this branch of the healing art from the hands of
quacks and charlatans ; and the names of those respectable gen*
ll«men who at present practice aural surgery in Great Britain are
a sufficient guarantee that the empiric and the nostrum-monger
will soon be driven from the field. Yet that some of those latter
still drive a thriving trade may be learned from the puffs and
praises bestowed upon them in the literary periodicals of the day.
In one of these, which, from our own knowledge of the honour
and integrity of its editors, as well as its hitherto stem and un-
compromising .stand against quackery of every description, and
its high reputation for honesty of purpose and substantial literary
merit, we really expected better things, it was some time ago not
only asserted, but endeavoured to be proved, that by dropping
** an alkaloid** into the external meatus, or rubbing the surface of
the membrana tympani with it, persons bom deaf and dumb have
been almost instantaneously cured I nay, not only is hearing re-
flared on the moment, but the miracle (for miracle it certainly is,
if true) extends to the organs of speech also, as in one caae, and
that too given on the faith of a medical man, and conveyed in a
letter to the operator, he says, that '* after repefUed examinations
of many of the objects under your care, previously to anything
being done, I satisfied myself that they were both deaf and dumb.
I have witnessed the application of your remedy to the ears, and
bear testimony to them having in my presence obtained the sense

44 TURNBULL Ain> HIS ESYIXWBBS.

of hearing.** But — miracle upon miracle — the fiusulty of speech
to one who had never heard the sweet sounds of a human yoiee*
follows almost as matter of course ; for, adds the narrator, <* and
by my own tuition, in a few miniUea a/tenoards acquired thepawtr
of speech F I wonder was it broad Scotch they spoke I

The history of this affair is as follows: — In 1837 there ap-
peared in London ** A Treatise on Painful and Nervous Affections,
and on a new mode of Treatment for Diseases of the Eye and Ear,
by A. Tumbull, M. D.'* The portion devoted to the considenh
tion of affections of the latter organ is comprised in six page8»
and the treatment consisted of the application of the alkaloid va-
ratria to the external meatus and the parts joining the auride.
'^ Feeling satisfied,** says the author, *' that I had in my possession
means decidedly effective in promoting absorption through the
medium of the nerves, and knowing that deafness often arose
from the Eustachian tube being obstructed by enlarged tonsil
glands, I applied vcratria externally over these glands, and found
it frequently succeed in removing their enlargement and restoring
the hearing.** The " electro-stimulation,** as the author terms it,
having been found so efficacious in removing deafness, such as
has been described in the foregoing quotation, he was induced to
extend its benefits to the deaf and dumb, and shortly afterwards
it was announced that Dr. Tumbull had cured several deaf-mutes;
and advertisements appeared in the newspapers for persons to in-
struct those patients cured by such means. The possessor of this
valuable discovery next proceeded to Scotland, to operate upon
the deaf and dumb portion of the inhabitants of that country, but
his cures were questioned, and his statements rather severely
criticised, in that valuable publication, Chamber's Journal, for
28th September, 1839. By some means, however, he afterwards
proved his case to the satisfaction of the Editors, and then, in
their publication for 8th January, 1842, No. 519, they acknow-
ledged, in an article headed '' Cures for Deafness," the in-
justice of their previous attack, and were equally loud in praise
of the cures said to have been achieved. Several of these cures
were said to have been effected upon children either in the Deaf
and Dumb Institutions of Scotland, or known to some of the

Chambers's journal. 45

principals of these establishments ; and consequently the late Mr.
Robert Kinniburgh, a gentleman of great truth and vast expe-
rience in the management of the deaf and dumb, addressed a
letter to the Editors, proving distinctly in each individual case re-
lated that no cure was effected. This letter, of which I possess a
copy, was published upon the 28th February, 1842, but it was
only privately circulated.

It is always a matter of difficulty to argue on a medical sub-
ject with a non-professional person, for it is quite impossible for
a man uninstructed in anatomy, physiology, medicine, and sur-
gery, to be convinced of his error, — to form an opinion of the
merits of a cure, or the causes of a failure. Such discussions with
non-medical persons should be avoided as much as possible, they
tend to no good, and were it not our conviction that Mr. Cham-
bers, for whom we entertain the highest respect, had been made
ike dupe of Dr. TumbuU, we would not thus have alluded to the
snbject here. How few students, after two, or even three years*
study in the preparatory and elementary courses, would be ca-
pable of estimating the value of any medical production put into
their hands I and yet, *' in order to ascertain in what respects
Dr. Tumbull's practice differed from that which is general in the
profession,** we were gravely informed by the Editors of the Edin-
burgh Journal, that they ^* studied the most recent and approved
works on aural surgery.** Had the writer known anything of the
structure of the parts he attempted to describe, he would have been
better informed than to publish an account of an analogy between
the ceruminous glands in the external meatus, and the mammary
gland in the female ; for in the article to which I allude he says :
** Finding cured persons relapse in consequence of the defect of
wax, Dr. Tumbull was prompted to use his ingenuity in endea-
vouring to discover a means of sustaining that secretion. He
reflected that the application of the mouth of the child to its mo-
ther*s breast, by removing the pressure of the atmosphere, causes
the milk immediately to flow, and he conceived that a similar re-
sult might follow with respect to the wax of the ears, if he could
hj any means remove the pressure of the atmosphere from the
external parte. For this purpose, he at first used a syringe with

46 chambbbs'b JoumvAL.

an Indian-rubber mouth exactly fitted to the aperture of the
ear,** &c. Now the veriest tyro in medicine knows that it does
not depend on any atmospheric pressure, but is owing to a mor^
bid action in these follicles themselves that the ear wax is not
secreted. But yet we read — *' the plan was successful ;** and the
reason assigned is, because ** the blood-osifalf resumed a free cir-
culation, and the flow of wax recommenced."

Again, we learn that ** the clearing of the Eustachian tube, for
which no means formerly existed but the application of medicinie
to the bowels, or the dangeroue use of a catheter, was affected by
Dr. TurnbuU by the same simple means." Well might the friends
and admirers of the Doctor employ the term dangerous^ for the
only record of any accident or ill-effect having arisen from the
employment of this exceedingly simple and harmless operalioD
occurred to Dr. TurnbuU himself, two of whose patients, in the
year 1839, fell victims to the operation of catheterism of the Eus*
tachian tube, and on both of whom coroner's inquests were held.
One of these, it appeared in evidence, was, almost immediately
after the operation, attacked with emphysema of the throat and
inflammation of the brain, of which he died in a week ; and the
other, a lad named Joseph Hall, aged 18, and in perfect health,
'* fell back in the chair apparently lifeless, and never spoke after-
wards."— (Lancet, July 6, 1839.) In the first of these cases it
appears most likely that the emphysema was caused by the instru-
ment rupturing and tearing the mucous membrane ; and in the
second, in all probability, the death was caused by the shock or
concussion given to the base of the skull by the volume of com-
pressed air, — ^for where the mouth of the catheter was we know
not After this it seems the Doctor changed his hand, and find-
ing that it was rather a " dangerous** experiment to '* blow up"
his patients, he determined to euck them as much as possible;
and, in order to effect this, Mr. Chambers informs us, that by
means of an air-pump, in connexion with a small glass tube,
'' introduced into the mouth of the patient, and applied to the
orifice of the Eustachian passage,** and consequently behind and
above the soft palate 1 communication is opened between the pre-
viously rarified air in the receiver and the orifice, from which a

IS THE DEAF-MUTE CURABLE ? 47

discharge of mucus is «oon made into the tube, which is then
withdrawn."

With one word more let us dismiss this subject of Dr. Turn-
bull and his reviewers ; — a word worthy of consideration to those
who may be induced by articles such as that to which I have al-
luded to submit their deaf-mute friends or relatives to useless
pain and profitless experiment; and many an anxious parent —
some from this country — upon the faith of the report then pro-
pagated, and relying on the truth of these cures, visited the
inventor of the alkaloid, and several spent considerable sums of
money in the vain hope of even once hearing their children arti-
culate. That word is this — and it is the more suitable on account
of the sanctimonious air assumed in the application of the means
employed, — Were the miraculous cures of the Saviour, who
dghed over the case of the deaf-mute, performed on cases or in
diseases that art, either then or now, could have remedied? —
could remedial agents, or man's interference, have raised the
dead — thrown instantaneously the vigour of youth, and the health
and strength of manhood, into the limbs of the cripple — given
power to the paralytic — steadiness to the palsied — and calmness
to the possessed ; or have cooled the fevered — given, by a word,
light to the blind, speech to the dumb, and hearing to the deaf?
— ^If, without the special interference of Providence, tliese indi-
viduals could have been cured, then their cases were not miracles;
but if without the pale of art, or beyond the power of human
means, then were they miracles, and cannot now be performed
but by similar means. That, however, the age of miracles was at
hand, Mr. Chambers appeared to have some idea, for, no doubt,
aware of the instantaneous restoration of speech and hearing to
the deaf-mute being one of the miracles assigned to Christ, he
concludes by saying: — *<* Every thing but trodden out of exist-
ence,' is, in one word, the fate of the individual who has been the
first Merely Human being to cause the deaf to hear.*"

Having many years ago discussed this subject,^ it is unneces-

• " ContriboUons to Aaral Surgery, Part II., The Early History of Aural Sui^ry,
with a Nosological Chart of Diseasce of the Ear.** — Dubliu Joomal of Medical Science for
July, lSi4.

48 IRISH AVD AMBBICAS WBITBB8.

sary to expatiate upon it further. The public should, however,
be guarded from these impostures, which are from time to time
offered for the cure of incurable diseases; among these, deaf-dumb-
ness— some cases of which are now, I understand, undergoing a
series of mesmeric experiments — is one of the most fruitful.

The various Cyclopaedias of Medicine published in Great Bri-
tain contain articles upon aural diseases ; among these. Dr. Cop-
land's '' Dictionary of Practical Medicine,** Article, Ear and
Hearing, Parts III. and IV., may be specially noticed, as embo-
dying a compilation of the opinions of the best authors on the
subject. T. Chevalier published in I^ndon a treatise ** On the
Cure of Polypi in the Meatus Auditorius Extemus with Sulphate
of Zinc,** in 1843; I have not, however, seen the book.

With respect to the Irish manuscripts to which reference was
made at p. 8, it could not be expected that works of that early
date would afford much information on an art which has within
the last few years only been raised to the level of surgical and
medical science. Several of these manuscripts contain curious
receipts for deafness, consisting chiefly of the juice of herbs, pre-
pared according to a particular formula, and dropped into the
external meatus ; among which the roots and flowers of cowslip
and the red mesmir mixed with honey, occur frequently ; saffron
and burdock boiled on vinegar, and roasted figs, were much em-
ployed ; and eel oil was then, as it is still, a favourite popular
receipt for deafness. In the Book of the O'Lees there is a chap-
ter devoted to the consideration of diseases of the ear, but^ like
most of the other writings of that period, it consists chiefly of an
enumeration of the '* cures** in most general use for deafness.

I am not acquainted with any native American work on
aural surgery ; and the medical periodicals of that country have
recorded but few cases of interest in connexion therewith. The
only book which I know is that of Saissy, <' An Eissay on the
Diseases of the Internal Ear, translated from the French, by Na-
than R. Smith.** Baltimore, 1829. The first volume of Baron
Larrey's '' Clinique Chirurgicale^ containing a chapter on Le-
sions of the Ear, was translated by Dr. Rivinus, of Philadelphia,
in 1832.

THE EDINBURGH SCHOOL. 49

Edinburgh has not contributed much towards aural surgery.
I know of but one special work on diseases of the ear which has
issued from the Press of that ancient and celebrated School of
Medicine since the time of Degravers, viz. ** Treatise on the Ac-
cessary Organs of Hearing, comprising the Special Pathology and
Treatment of their Diseases, by James Mercer, M.D.,** which was
written, I understand, as a probationary essay for the Fellowship
of the College of Surgeons in 1840. In the Monthly Journal for
March, 1848, will be found a very useful paper on the pathologi-
cal sequences of acute inflammation of the fibro-mucous structure
of the cavity of the tympanum, by the same author.

In the Monthly Journal of Medical Science for 1845 and 1846,
Dr. A. Warden, " Aurist in Ordinary to the Queen," published
papers on the Inspection of the Meatus Auditorius Externus.
This gentleman fixed to the ordinary tubular speculum a prism
for the purpose of polarizing light, — a totally useless addition.
In 1847 he promised a work on the subject, of which the follow-
ing is the advertisement, as it appeared in one of the Scotch
newspapers : — *' In the Press, and shortly will be published, the
Nature and Treatment of Diseases of the Ear, as more fully re-
vealed by the Prismatic Auriscope ; with fifty coloured Delinea-
tions of Natural and Diseased Conditions. — * With the Prism in
our hand we may now go forward as with a torch powerful
enough to dispel all obscurity, and to enable and entitle us to
plant the union-jack of the profession on the whole domain in the
usual form of maps and delineations of disease.' — Preface!^ Nei-
ther work nor preface ever appeared, and criticism of the dead
would now be ungenerous.

While these pages are passing through the press, Mr. Harvey,
of London, whose writings have been already alluded to at p. 35,
lias issued another work, entitled, <* Rheumatism, Gout, and Neu-
ralgia, as affecting the Head and Ear; with Remarks on some
forms of Headach in connexion with Deafness." In it the author
appears to be under the impression that he is entitled to originality
for his views, — my answer to that will be found at pp. 225 and 267.

The literature relating to deaf-dumbness will be considered in
the section bearing on that subject.

E

50 REQUISITES FOR AN AURAL SURGEON.

What is the legitimate aural practitioner in the present day,
and how far does his art extend over disease ? A practitioner in
aural surgery, or, if it pleases the public to call him, an Aurist, in
our day must, or at least he ought to bo, a well-educated surgeon
or physician, who applies the recognised principles of medicine
and surgery to diseases of the organs of hearing, in the same
manner as the modern ophthalmic surgeon does to diseases of the
eye. We daily hear and read, and it has been reiterated from
mouth to mouth, and copied from work to work, that the treat-
ment of such affections is an opprobrium to the healing art, " in
surditate quidnam eat male^ and that deafness is without the pale
of human knowledge. Now notwithstanding the injudicious treat-
ment by quacks and nostrum-mongers, the neglect of patients,
and — as in many instances we know it is — the total abandonment
of all treatment by the general practitioner, still, were the statis-
tics of all diseases carefully collected, it would be found that there
were among them as many curable cases of affections of the ear
as there are among the severer maladies of the eye, or among dis-
eases of the chest, the brain, the liver, or any other organ. Up to
a very recent period, from well-educated medical men in this coun-
try either considering it beneath their station or acquirements to
treat so insignificant an organ specially, or not finding in the
direct cultivation of aural surgery a sufficient remuneration for
their time and talents, this branch of the healing art remained
in the state in which ophthalmic surgery was half a century ago.
All this — added to the smaller share of sympathy afforded to the
deaf than the blind ; to impairment of hearing interfering less
with man's means of subsistence, and also to the great difficulty
of cither minutely examining during life, or of investigating after
death, the morbid changes which occur in the middle and intei^
nal car — serves to account for aural surgery and pathology not
having kept pace with the other rapid improvements in medical
science. Yet the well-instructed aurist of our time possesses a
knowledge and a power which is not general among the profes-
sion— of making an accurate diagnosisy which, when given with
honesty, will frequently save the patient much anxiety, unneces-
sary suffering, and loss of time and money.

61

CHAPTER II.

MEANS OF DIAGNOSIS, AND APPLICATION OF REMEDIES.

Plan of the Work. — Records of Cases. — Means of forming a Diagnosis, and mode of

Examination Physical Signs. — InstrumeDts and Remedies. — The Auditory Canal

and Membrana Tympani. — Lamps, the various forms of. — The Speculum. — Eusta-
chian Catheterism. — The Stethoscope.— Syringing The Hearing Distance. — ^The

Throat. — The Yoioe.— Tinnitus. — Subjective Symptoms. — Depletion. — Leeches. —
Counter-Irritation. — Galvanism and Electricity. — Mercury, &c.

HAVING in the preceding chapter offered some remarks
upon the subject of Aural Surgery generally, and given a
short outline of the history of the art, I will now explain the
plan which I have adopted in the following chapters. At the
commencement of each I have given a brief anatomical descrip-
tion of the parts concerned in the affections under consideration,
and a concise account of their most remarkable malformations and
congenital diseases ; afterwards, the etiology and treatment of
those diseases with which I am myself most familiar are described.
I have followed that division into the diseases of the external,
middle, and internal ear, because it seems to facilitate description,
as well as to make the most lasting impression on the mind of the
student. The work concludes with a section on deaf-dumbness,
which contains the result of the inquiry set on foot under the
Irish Census Commission for 1851, and which I have compressed
from the official Report upon that subject*

From 1843 to the present time I have published several essays
and monographs on diseases of the ear in the Dublin Journal of
Medical Science, the Dublin Quarterly Journal, and the London
Medical Times.f The substance of these essays, modified by sub-

* See also the Author's paper on the Statistics of Deaf-dumbness, communicated to
the British Association at Belfast, September, 1852, and published in the Journal of
the Statistical Society of London, for March, 1853.

f The earliest of these essays— Upon the Causes and Treatment of Otorrhoea, — that by
which the tubular speculum was first introduced in this country, — appeared in the First

e'2

52 RKC0RD8 OF CA8S8.

sequent knowledge, and amplified by whatever improvenients had
been made in the art since their publication, I have reprinted in
this work. Those diseases of the ear with which I am not myself
acquainted I have briefly enumerated and described, and given
the references for their authenticity.

In an art but just emerging from the mists of quackery, which
have until recently enveloped the pathology and treatment of
diseases of the ear, it is of great importance to accumulate facts,
and openly, fairly, and fearlessly to state the truth, even at the
expense of what is termed popular reputation. Observing in the
periodicals, from time to time, records of "cures** of deafness, and
aural affections, which evidently prove their authors to be un-
acquainted with the ordinary pathological appearances of such
diseases ; and moreover, seeing daily *' causes of deafness** put
forward in books and papers, which, according to my experience,
rarely, if ever, exist ; and furthermore, hearing, and having con-
tinually brought under my notice (although, curious to relate,
generally by persons who are themselves incurably deaf), ac-
counts of success in the treatment of deafness in other parts of the
United Kingdom, which I do not and cannot credit ; — I determined
to make an accurate note of every case of disease of the ear
among the patients who applied at the Hospital for twelve months
in succession. I believe it to be of the greatest importance, in
the present state of our knowledge, to accumulate facts, and to
make the profession at large acquainted with the appearances
which any deviation from the normal or healthy state presents in
the ear ; and I have also thought it useful to fiuniliarize the

Series of the Dublin MedicAl Journal, for January, 1844, voL xxiv. p. 818, as Part L
of ** Contributions to Aural Surgery." This Essay, which met with a very fkvonrabls
reception on the Continent, was translated into German, and published separately by Dr.
Von Uaselberg, of Stralsund, in 1846, and afterwards large portions of it were translated
by Dr. Schmalz, of Dresden, in 1848. Part u. — Upon the Eariy History of Aural Snrgeiy,
with a Nosological Chart of Diseases of the Ear, already referred to at page 47 — was pub-
lished in the same periodical for May, 1844. Part iii. — On the Inflammatory Affections
of the Membrana Tyropani and Bliddle Ear — was printed in the Dublin Quarterly Journal
of Medical Science, No. viil, for November, 1847, and No. XL, for February, 1848. The
Practical Obser\'ations on Diseases of the Ear, with the records of cases alluded to in the
text, were commenced in the Medical Times for Ifarch 29th, 1851, and have been oon-
tinned until the present time.

BBCOBDS OF OASBS. 53

pupils attending the Institution over which I am pbu^ed with
those methods of examination which will best enable them to form
an accurate diagnosis and prognosis.

Each case, as it presented, was accurately investigated in the
presence of a class of advanced students and young medical men ;
the most prominent symptoms were noticed, the pathological con«
dition of the parts demonstrated, and a few remarks made upon
the cause of the disease, its prognosis, and treatment. Occa-
sionally the students, under my direction, conducted the examina*
tion. A short-hand writer, familiar with medical terms, who was
always in attendance, recorded with accuracy what passed. These
notes, when reduced to writing, I my self corrected, and frequently
compared with the appearances presented upon the patient's next
attendance. By this means a vast amount of time and labour was
saved, and the diseases being thus noted by myself, without the
usual intervention of a *' case-taker,** I believe them to be more
accurate than those usually related in medical writings. By this
means a vast amount of information was collected. In most of
these clinical cases a running comment is, as might be expected,
mixed up with the description, — a more colloquial, but perhaps not
less useful, form of instruction than that commonly met with in
medical books and periodicals.

As far as progress and the effects of treatment are concerned,
many of these cases are very defective, because, in a burge public
Institution, as every one knows who is extensively engaged in
treating the poor, it is not possible to follow out their history.
Several of the persons applying for relief, having little hope held
out of ultimate restoration to perfect hearing, do not return a
second time ; others are kept away by their respective avocations;
and many of them, having changed their residence, have found it
inconvenient to attend. Unsatisfactory as these drawbacks are,
and must always be under the like circumstances, I think the pub-
lication of an abstract of these cases will be so far useful, by en-
abling the profession to judge from what causes deafness most
usually arises, and what morbid appearances most commonly
present. Some of these cases, exhibiting types of disease, have
already appeared in the '* Medical Times."

54 BSCORDS OF 0A8BS.

In noting these cases, in some instances the objective^ and in
others the subjective symptoms, have been first recorded; bat the
accounts which even educated people give of the history of thdur
deafness are frequently most incongruous, and often puxzling ; and
the apathy and indifierence with which persons in all ranks of
life have allowed the insidious approaches of aural disease to cie^
upon them are really marvellous. Mr. Saunders, with whose
luable essay upon the ear I wish the profession were better
quainted than they are, remarked upon this subject, in his own
peculiar lucid manner of expressing himself, nearly half a cen-
tury ago : — ** A clear and distinct recital of symptoms is rarely
obtained from the deaf They are conscious of their infimu^, bat
very few are impressed with a notion that hearing may be im-
paired by a variety of causes. The approach of deafness is inadions,
and often unaccompanied with pain. Few strong impresrions are
made on the mind of the patient, and he loses his (iu^ulty of hear-
ing so imperceptibly, that in general his friends sooner discover
his misfortune than himself**

With respect to the mode of conducting the inquiry in the
Hospital cases, I may remark, that where a patient presented
with a totally Incurable disease, a second note has rarely been re-
corded ; indeed, the patient has always been discouraged attend-
ing the Institution. It is less likely to bring discredit upon the
art when people are honestly told that, owing to their own neglect^
or to their improper treatment, the time has passed by for afibrd-
ing them relief, than to allow them to continue for weeks or
months in attendance, and often at a great expense of time. This
observation holds good in private practice even more than in the
management of institutions, or in treating the poor.

As in all diseases, so especially in aural affections, the first
grand point is accuracy of diagnosis, without which all treatment
must be empirical, and to arrive at which it is indispensably ne-
cessary that we should be thoroughly acquainted with the best
mode of conducting an examination. For that reason, and be-
cause it is in it I find both the practitioner and student most fre-
quently at fault, I have in the following pages dwelt at greater
length and entered more minutely into that part of the subject,
than is usual in works of this description.

METHOD OF EXAMINATION : — THE AURICLE. 55

Passing for the present the subjective symptoms, which will
best appear in the words of the patient, let us inquire into the best
method of forming a diagnosis from the physical signs presented.
The patient being placed opposite strong, direct sun-light, —
with the head inclined at such an angle that the sun^s rays may
&11 directly through a tubular speculum upon the membrana tym-
pani, — we first carefully observe the condition of the concha, ex-
ternal meatus, mastoid process, infrazygomatic region, and the
space immediately below the lobe of the ear. The auricle^ its
various folds, its colour, its temperature in particular, its thickness
as learned by feeling its hem or helix between the fingers, and
the angle which it forms posteriorly with the cranium, — together
with the position, size, shape, and colour of the external meatus^
as seen without altering the relation of the parts, — should be speci-
ally noticed. The upper rim of the helix should then be grasped
between the finger and thumb of one hand, and drawn upwards,
backwards, and outwards, while the thumbof the other hand, placed
in front of the tragus, by drawing it and the integuments forward
upon the zygoma, exposes the outer third or more of the auditory
canal to view. This little gorget-like instrument will also be
found useful
in examining
the external
aperture. The
finger should

then be pressed deeply and firmly upon the moveable root of the
tragus^ and backwards into the depression between it and the
articulation of the jaw. While the finger is retained in this posi-
tion the patient should be desired to open and shut the mouth|
and the amount of pain or inconvenience experienced by pressure
in those two different positions of the jaw accurately noted. The
middle and fore-fingers should likewise be inserted deeply behind
the ramus of the jaw towards the styloid process, and notice
taken of the sensations there experienced.

Where we have reason to believe inflammatory action exists,
the maMaid process in an especial manner claims our attention.
Its colour, size, shape, and temperature, may be learned by even a

56 THE MASTOID BSQIOIT.

cursory examination; but, besides this, it should be moeicaiefiiUy
pressed upon with a couple of fingers, with a much greater d^iee of
force and firmness than is usual in making examinations of the like
nature elsewhere ; and this examination should not only be applied
to the mastoid region, but to the whole posterior and lateral portion
of the head, if we have reason to suspect any inflammation, or its
effects. The insertion of the sterno-mastoid, as well as the upper
third of that muscle, should also be carefully examined in the
same way, as there is a small gland, in shape and size like a hone-
bean, situated immediately behind the auricle, over the middle of
the mastoid process, which frequently becomes enlarged during
the progress of aural inflammations, and is also the seat of violent
neuralgic pain in some instances. If the integuments and soft
parts are swollen or (Edematous, as is frequently the case in cer-
tain inflammatory affections of the ear, as also where they have be-
come thickened from long-continued disease, it will require a con-
siderable degree of force to make a perfectly satisfactory exami-
nation. The amount of pitting made by the finger during this
examination, and its degree of permanency, are also circumstances
of value in the formation of a diagnosis. Percussion of the mas-
toid process, immediately behind the attachment of the auricle,
occasionally affords some information, as will be shown in some of
the cases hereafter detailed.

We next proceed to inquire into the condition of the audUary
canal, and external surface of the membrana tympani. To effect
this, and to explore every portion of the surface of these partSi it
is necessary to resort to the mechanical assistance of the speculum ;
first taking care to remove any impaction of wax, accumulated dis-
charge, or other mechanical impediment which may exist and ob-
struct our vision. If this obstruction is complete, and that we have
reason to suppose that it is the chief cause of deafiiess, the em-
ployment of a syringe and some plain warm water is the best mode
of removing it; but if the obstruction merely co-exists with other,
and particularly with some of the inflammatory affections of the
meatus or tympanal membrane, or if it be only partial, and con-
sists of portions of detached cuticle, hairs, or scales of hardened,
inspissated cerumen, it is better to remove these gently with a

THE EZTBHHAL ADDITOBT CANAL.

57

pair of fine foiceps, because the very act of syringing, even
with wann water, caueee in a healthy car an inoteased vascu-
larity, which will mask the actual amount of disease present
The same observation applies also with respect to alight otor-
rhoea, but if there be much discharge present, we must have re-
course to the syringe. Having found that the handles of the
instruments introduced through the tubular speculum and the
fingers of the operator interfere to a certain degree with the direct
eua-rays, I have Utterly had instruments constructed with an
angle in (he shaft, as showa in the accompanying view of a pair
of ear forceps, the utility of which is at once manifest.

Up to a very recent period we possessed no better means of
examining the external meatus and the mcmbrana tympani than
that afforded by the usual ear speculum, made somewhat in the
form of a crane-bill forceps, and derived, with various modifica-
tions, from the time of Fabricius Hildanus. Itard, DcleaUiVerret,
Robbi, Kramer, and others have improved upon this speculum,
which was that in general use in this country until I introduced
the tubular form in my Essay on Otorrhcea. Another description,
with three arms, and opening by a screw in the form of a vagina
speculum, was manufactured by Mr. Weiss, on the supposition
that the external auditory passage could be increased in caliber by
mechanical means, and Hoffman has publislied an account of a
somewhat similar instrument in" CiMpcr'sFTocAenscfiri/if" for 1841.
la making examinations of the meatus and mcmbrana tympani
with any of these instruments, the chief requisite is a itnmff dire<i
light, transmitted without interruption to the tympanal membrane,
or that portion of the passage which we wish to examine. This is
best effected by means of the sun's rays, but as the ordinary spe-
calum can only dilate or straighten the external cartilaginous por-
Uoa of the passage, a person accustomed to aural examinaUons can

58 THS DIFFBftBVT KIVIM OF LUIP8.

frequently, especially where the meatuB is of a large dae, obaenre
the tympanal membrane, or at least a portion of it» without, as
well as with, such an instrument, by merely lifting up the auricle
with one hand and pressing the tragus forward with the thmnb
of the other. The light must, however, be strong, and made to
fiedl directly upon the passage. In all such examinations tiie patient
should be seated beneath the examiner, with the head slightly
bent, opposite a window through which the wn is M»dng at the
moment, and, if possible, between the hours of eleven and three.
Artificial light has been recommended, but it is not so re-
quisite in this as in other countries. In Vienna, for instance,
during the winter months, there are many days on which
there is not sufficient sunlight for accurate aural examinations.
Cleland used a convex glass, which was held before a wax candle
in order to concentrate the rays of light into the meatus. To
this apparatus Bozzini added a concave mirror, but without
much effect; Deleau further modified it by placing a lighted
taper between two concave mirrors. The invention of the instru-
ment of this description which possesses greatest power is un-
doubtedly due to our countryman, Buchanan, the principle of
whose lamp exhibits an evident acquaintance with the laws of
light, and the mechanism of optical instruments. This was sub-
sequently improved upon, and its effects increased by Kramer,
who substituted an argand lamp for tiie comparatively feeble wax-
light of the original inventor. This instrument, which in form,
construction, and effect, very nearly resembles a common magic
lantern, consists of a tin box, having its interior blackened, and
being provided with a strong lamp and powerful reflector, op-
posite which there is a tube containing two convex lenses, each
two inches and a half in diameter. In using tiiis apparatus, a
disc of strong light, about the size of a halfpenny, is thrown upon
the opening of the meatus, a portion of which light is, by means
of any of the ordinary specula straightening the cartilaginous por-
tion of the tube, transmitted to the membrane of the drum. Now,
independent of the inconvenience of this lamp, I may remark that,
although it undoubtedly illuminates the passage and membrane
very powerfully, yet the peculiar lurid glare which it throws upon

THE DIFFBB£NT KINDS OF LAMPS. 59

every object decidedly prevents the examiner observing with
accuracy those conditions of the parts — as in inflammation, &c. —
where colour and the character of the vascular arrangement forms
the chief means of true diagnosis ; and even Ejramer himself is
forced to acknowledge that ''no artificial illumination can equal
the light of the sun*s rays, or render this light imnecessary, on
which account it must always be had recourse to in important
cases, e. g. in operations in the vicinity of the mcmbrana tym-
pani.^ All lamps possess these two radical defects : — One is, that
although an irregularity of surface, a polypus, an aperture in
the membrana Qrmpani, or the like, may be detected, yet shades
of vascularity produced by inflammation or congestion, speckled
opacities, minute points of morbid deposit, and slight ulcerated
abrasions, want of polish, and loss of transparency, &c., cannot be
detected by their means. And again, although we were able to
detect an ulcer, a granulation, or a perforation, we could not be
able, while the eye is fixed upon the spot, to apply any direct re-
medy to the part affected, — or pass down aporte-caustic, a forceps^
a snare, or a camel-hair brush. How, for instance, could a hair, no
uncommon cause of annoyance, be removed off the surface of the
drum but through one of these lamps? No obstetric practitioner
thinks of examining the os uteri or the surface of the vagina with
a lamp, so long as the suti's rays can be directed through a tubu-
lar speculum to the parts affected.

The instrument which I have here described is now generally
known under the name of Kramer^s ear lamp. Buchanan's appa-
ratus is represented in his "Illustrations of Acoustic Surgery,"
and all the various lamps and forms of specula are figured in
Lincke's Handbuch der Ohrendheilkundey and in Frank's Practiache
AfUeUunfff page 38 to 61. In most modern English works, how-
ever, we find a copperplate of ear instruments, particularly those
of Kramer, Lincke, and Schmalz, but in addition, though without
much difference, we see a figure of " the author's catheter,** " the
author's lamp," &c. &c.

Two portable ear lamps have been produced in England
within the last few years, one by Mr. Jordan of Manchester, a
very ingenious instrument, and useful when artificial light is

60 THB TUBULAB 8PS0ULUM.

either applicable or alone available, as at nighty or in a sick-room
when the patient cannot be moved to the light with facilitj. It
consists of a small box, containing a lighted taper and two me-
tallic reflectors, one of which is set at an angle in the bend of a
projecting arm, which throws a stream of light on the membrana
tympani, through a fixed tubular speculum inserted into the mea-
tus, while the operator looks through a narrow tube containing
two small lenses ; but, like all such instruments, it is objectionable
on account of the peculiar red glare it throws upon the parts under
inspection. Mr. Averey's reflector, which is a very well^con-
structed instrument, is also liable to the same objection.

In 1827 Dr. Newburg, in his Memoir d ObsenxUUms sur la Per-
fonUion de la Membrane du Tympany published at Brussels, recom-
mended a slender horn tube, nearly four inches long, with a bell
muzzle. This instrument, which is much too long, was the origin
of the different varieties of tubular specula now in use. Subse-
quently Dr. Gruber, of Vienna, improved upon Newburg's idea,
and to him I am indebted for the instrument of which I published
an account in 1844.

Having found that all the instruments heretofore invented for
exploring or operating upon the external auditory passages were
defective, as a means of tranemittinff lights which is the only real
object of a speculum, — for it is a mistake to suppose that any ap*
paratus can do more than straighten and dilate the external aper-
ture and external third of the tube, — I have always employed
the tubular speculum for this purpose. This little instrument,
formed upon the principle of that invented by Dr. Newburg, and
described in the preceding paragraph, I first saw used by Dr.
Gruber, but employing it as he did with the artificial light of Kra-
mer*s lamp, he had not the same opportunities of testing its value
and utility. These instruments consist of conical silver tubes
of different calibers, such as those represented in the accom-
panying wood-cut, each tube or speculum being an inch and a
half long, five-eighths of an inch wide at the greater aperture,
and varying from two to four lines in the clear at the smaller ex-
tremity. Larger and smaller sizes will be occasionally necessary,
but for the greater convenience of carrying in the pocket, I gene-

THE TnBULl.B BFECULDH.

61

rally order a set of three, fonned so as to fit into one another, and
corresponding in size to the representations below. They should
be made as light as possible, highly polished both inside and out,
with a stout rim or burr round the larger margin, and the smaller
aperture well rounded off, so as not to irritate the ear in entering.

I have tried them of various sizes and shapes, and their sides run*
ning at different angles, as well as with the interior blackened,
so as to prevent reflection of the incident luminous rays, but those
which I have described above I find to answer the purpose best
In unng this speculum, the various sizes of which are adapted to
different ages and varieties of aural aperture, the patient must, if
possible, be seated opposite the light, and the head placed at such
an angle as that when the instrument is introduced into the mea-
tus, the rays of light will fall directly through it upon the mem-
brana tympani. While the auricle is drawn upwards and back-
wards with one hand, this little tube is inserted into the meatus with
the other, and is pushed in as far as possible without giving pain;
the head of the patient and the tube also are then moved slightly
irom side to side, and the inclination or obliquity of the latter al-
tered till a full stream of light falls upon the tympanal membrane.
In making this examination the operator must be careful to keep
his own head out of the l^ht, the interference of which is a very fre-
quent cause of failure with those unaccustomed to aural examina-
tions; the shadow of the head should fall a little above or a little
below the sphere of the speculum, according to the sun's elevation
at the moment; and I need hardly mention that but one person
can make this exploration at a time. As the tube is generally

62 THB TUBUULE 8PBC0U7M.

arrested, in normal ears at least, by the narrow portion of the mea-
tus at the junction of its middle and external thirds, we may then,
by gently rotating and moving from side to side the larger aper-
lure, which is held between the fingers, direct the stream of l^hl
so as to play upon any part in particular all round the meataa, im-
mediately external to the membrana tympani, and by withdraw-
ing it slightly, each portion of the passage may be thus accurately
examined in detail. By this means every part of 1^ extcraal
auditory tube, and the membrana tympani, and even the position
of the malleus within it, may be as distinctly seen and as carefully
examined as any portion of the external surftce of the eye;
whereas, with the ordinary hinge-moving speculum, I have in
many cases been unable to satbfy myself as to the exact oonditicm
of the membrana tympani ; and that this is daily experienced
by surgeons, I have, in addition to their own acknowledgments^
the fact of cases constantly presenting themselves, in which a
diagnosis had been made as to the state of the membrana tym-
pani, totally at variance with truth, and which arose firom their
inability to see and examine it with the usual instruments. To
attempt any degree of dilatation of the auditory passage by means
of instruments shows a want of anatomical knowledge in their
inventors, as the most any speculum can effect is to straighten the
external cartilaginous portion of the tube, and thereby allow the
light to play upon the interior. Had the accurate and honest-
minded Saunders possessed this means of examining the ear, he
certainly would not have stated that he had '* never observed
these excrescences'* (polypi and granulations) *' in the meatus ex-
temus when the tympanum was sound.'* Another great advan-
tage which this funnel-like speculum possesses over all others is,
that it remains fixed in the ear, causing scarcely any incon-
venience, and leaving one or both hands free for the application
of instruments if necessary. It is also much more easily used with
young children than any other.

From a long and most extensive use of the tubular speculum,
I am convinced that it is not only the simplest, but also the most
effectual instrument for examining the condition of the membrane
of the tympanum and the external auditory canal. Various other

THE TUBULAR SPECULUM. 63

instrumentSy tubes with prisms, such as that invented by Mr.
Warden, and mentioned at page 49,* and divers lamps, have been
recently contrived, and their virtues set forth in graphic terms
by their inventors and supporters, but they are all comparative
fiiilures, because they cannot enlarge the osseo-cartilaginous por-
tion of the canal near the tympanum ; and the prisms are totally
unnecessary, and even disadvantageous, where direct light can
be procured.

I have dwelt thus long upon the subject of the speculum, be-
cause without it it is impossible to form an accurate diagnosis,
and because it is the want of the proper employment of this in-
strument which has led to such gross errors in practice. Modifi-
cations of it have been devised by others, and possibly in their
hands they may be found more useful than that which I employ.
I believe, however, it is a well-managed light (natural, not arti-
ficial light), a practised eye, and delicate manipulation, that,
more than any peculiar form of instrument, assists the practi-
tioner effectually to explore the external auditory passage or
the middle ear, and which enables him to make an accurate
diagnosis.

It is no small gratification to me, to find that my labours to
make the profession in this country acquainted with the best me-
thod of examining ihe ear have been attended with some success.
An ear speculum has now become a necessary appendage to the
assortment of instruments which a surgeon usually carries about
with him, while but a few years ago such a thing was unknown —
in this kingdom at least. People are also beginning to find out that
something may be done for deafness, and that therefore it is worth
while attending to diseases of the ear in the beginning. I do not
expect that the prejudices of centuries will be got rid of in a day,
nor the neglect of years recovered in an hour; but I have, within
the last three or four years, observed a manifest improvement in
the mode of treating diseases of the ear among all classes of the
profession.

The form, curvature, colour, polish, vascularity, and the se-

* See Medical Gazette for 24th May, 1S44.

64 EXAMIHATIOH OF THB MBMBRAVA TTMPAHI.

crction of the entire auditory canal should be accurately noted,
and having brought the whole of the passage and the entire of the
mcmbrana tympani under our view, we must take accurate note
of their relative positions. In this case we suppose the external con-
duit free from accumulation of wax, muco-purulent discharge, or
other impediment that might obstruct our view. Should, however,
such exist, they must be now removed, in order that we may gain
a clear, uninterrupted sight of the parts they cover. Without any
abnormal secretion, however, we often meet with so much cerumen
as parUally interferes with the examination, and this may be gently
removed with a small spatula or a probe rolled round with cotton,
as by syringing in such cases we increase the vascularity, and so
mask the natural appearances.

The tympanal inefnbrcau^ in an especial manner, claims our
attention ; not only its superficial colour, but its degree of trans-
parency or opacity, its tenuity or thickening, its vascularity,
and the arrangement and position of its vessels in every part, —
its tension, flexibility, polish, curvature, and its position as re-
gards the interior of the cavity, of which it forms the outward
boundary, — and also the direction and projection of the handle of
the malleus, and the characters of the membrane, both above and
below the attachment of this bone, should be carefully observed.
While the membrane is thus within the field of the speculum, the
patient should be desired to try and press air into the drum by
holding the nose, shutting the mouth, and making a forced expi-
ration. This manoeuvre should be resorted to several times, if the
first be ineffectual, as some degree of tact on the part of the pa-
tient is necessary to test the experiment The sound thus pro-
duced is a sort odJiug^ and very much resembles that of a dried
bladder suddenly inflated with air. In order to become familiar
with it, one should practise it on himself. While the air is thus
pressed into the drum we should note accurately whether the
membrane vibrates, or its tensity is altered, and if so, whether it
regains its original position suddenly or gradually. The patient^s
own sensations should likewise be taken into account in this mat-
ter. It is also necessary carefully to observe the degree of vascu-
larity produced by this inflation, as well as the course and position

AUSCULTATION. 65

of the vessels which cause such vascularity, for even in several
healthy ears, if this experiment is made two or three times, we
seldom fail to recognise one or two vessels becoming filled with
red blood along the course of the malleus ; and if a small aperture
exists in the membrane which may have previously escaped the
eye, we may then readily detect it both by sight and hearing.
By this means we often discover a perforation, which, from its
minuteness, or owing to the part being thickened or coated with
discharge, had not been noticed during the ocular inspection.
If such exist, we shall then see its open, everted lips sometimes
pressing out mucous discharge, and also hear a peculiar whistling
sound which the air makes in passing through this narrow aper-
ture. There are, however, some cases of perforate membrana
tympani, where, from obstruction in the upper part of the Eusta-
chian tube, or granulations in the middle ear, this cannot be
effected. If the patient be able to inflate the tympanum by this
method, we may then remove the speculum, and, applying our
own ear, either directly or through the intervention of a stetho-
scope, placed over the external auditory passage, the same method
of inflation should be again had recourse to, and the peculiarity
of sound which is thus produced in the middle ear, whether the
ordinary normal rush of air, or a prolonged squeeling or gurgling
sound, such as might be caused by any contraction in or thicken-
ing of the walls of the Eustachian tube, or by dryness, or by ac-
cumulation of mucus either in it or in the cavity of the tympa-
num, is heard. The stethoscope should also be applied over the
mastoid process, and the same scries of observations made upon
the sounds, if any, produced there ; but these latter can seldom be
heard distinctly.

If the patient be unable to inflate the tympanum, and that we
have reason to suspect some obstruction of the Eustachian iube^
or an accumulation of mucus, blood, pus, or other matter, in the
middle ear, we may then, should the case require it, proceed to
inject air, by the mechanical means of a pump, an elastic tube,
and a catheter, into the cavity of the tympanum, while we care-
fully note the result by means of a stethoscope, or by the ear
applied externally. It must, however, be particularly borne in

66 THE AIR-PRE88.

mind, that if the patient is labouring at the time under acute in-
flammation of the drum or its membranes, or the lining of the
Eustachian tube, the catheter is not only inapplicable, but highly
injurious. I have latterly found it very seldom necessary to re-
sort to this operation, as the cases in which it is applicable are of
much greater rarity than is usually supposed, or as the works of
aurists would lead us to believe. Still, as exploration through
the naso-tympanal passage is a valuable means of diagnosis, it
should be here described. The early history of the operation has
been detailed at page 11. A great variety of instruments and se-
veral ingenious machines have been invented for injecting atmos-
pheric air, gases, medicated vapours, and fluids, into the middle
ear through the Eustachian tube. These consist of catheters of
different curves and calibers, and formed of flexible and inflexible
materials, and a great diversity of complicated mechanical appa-
ratus for pressing air or fluids through these, from a simple blad-
der or elastic bag, or a bellows, to an air-press, which com-
presses and condenses a certain volume of atmospheric air by
means of a forcing-pump into a chamber furnished with a stop-
cock, to which the catheter may be connected through the me-
dium of a flexible tube. That devised by Kramer, and figured
in his work, is by far the best and most easily managed. The
pump which I am in the habit of using was manufactured for me
in 1841 by Mr. Weiss, and is figured at page 70. It may not be
so easily managed as that of Kramer, in which the piston rod is
worked by a long lever, but it possesses the advantage of having
the receiver quickly and more effectually charged. This instru-
ment is fourteen inches high, exclusive of the piston rod, and
four and a half in diameter. The cylinder of the force-pump,
which rises above the surrounding receiver, and passes into it for
about two-thirds of its depth, is provided with valves through
which the air is accumulated in the latter to the required extent
Generally six or seven actions of the piston is sufficient for this
purpose.

The catheter which I am in the habit of using with adults is
that here figured of the natural size ; smaller ones may be required,
but a silver instrument like this, well smoothed and rounded at the

THE EUSTACHIAN CATHETER. 67

point, and of as large a size as can with facility be introduced
through the nose, is less likely to do mischief, causes
less irritation, is less liable to catch in the mucous
membrane, and is more apt to adjust itself to the bell
or trumpet-shaped mouth of the Eustachian tube, than
one of a smaller size, or composed of a flexible mate-
rial. Even the elastic catheter can only be introduced
with a stilette, the withdrawal of which causes consi-
derable irritation, and generally disadjusts the point
of the instrument. Some people even at the present
day assert that the catheter can be introduced through
the mouth, and others recommend it to be passed
above the lower turbinated bone of the nose. And
again we hear it stated that the instrument being once
fixed in the Eustachian tube, it will remain there, or
the patient may be directed to hold it in that position
until an inflated bladder, a bellows, a syringe, or a
gum-elastic bag, charged with fluid, is attached to its
extremity, and the contents discharged through it into
the middle ear. It would occupy too much space to
enter minutely into the objections to each of these
statements or modes of proceeding. I do not believe
they are generally feasible, and this is an opinion in
which I am sure the most experienced aural surgeons
will agree with me. Along the floor of the nose is,
in the first instance, the most ready access to the
Eustachian tube ; but, supposing that we have passed
the instrument with the greatest facility, and are quite
sure that the beak has turned into its faucial opening,
we must always bear in mind that not much more
than half, or at most three-quarters, of an inch of the
curved portion of the instrument has passed up into
the tube, and that the slightest movement on the part
of the patient, either of the anterior naris, which is
irritated by the foreign body, or the top of the pha-
rynx, where all the parts concerned in deglutition are more or
leas strained and excited, may disadjust the instrument. The

f2

68 CATHETEBISM OF THE EUSTACHIAN TUBE.

slightest effort at deglutition, even the act of swallowing the saliva,
will often effect this, as we may perceive, by observing the altera-
tion in the position of the ring at the end of the catheter which
projects beyond the nose. It fortunately so happens, that nausea
is seldom produced if the instrument has been carefully and
delicately introduced. In order, however, to obviate the diffi-
culties which I have just referred to, and to keep the instrument,
when once properly adjusted, fixed in the right place, mechanical
contrivances have been devised, of which a sort of vice — the plate
of which is fastened upon the forehead, immediately above the
root of the nose, by means of a leather strap furnished with a
buckle, which passes round the head — is the handiest. Upon the
front of the metallic plate is a ball-and-socket joint, in which re-
volves the little vice, or forceps, which is set on at a right angle,
and should come down over the anterior opening of the nose.

The patient being seated in a chair with the head supported
against a high back, specially constructed for the purpose, and
the fix)ntlet put on as I have described, — with the fore-finger of
the left hand elevate the point of the nose, and then with the
right hand insert the catheter, with its beak turned outward into
the angle between the floor and external wall of that cavity ; pass-
ing it rapidly over the floor of the nose, a dexterous and well-
practised operator will frequently hitch it into the sulcus of the
Eustachian opening at the first attempt, and is conscious of the
fact by that tactus eruditus which nothing but extensive ex-
perience can give, but which it is very difficult to describe. We
can often feel the catheter grasped by the mouth of the Eusta-
chian tube. If, however, we have missed the aperture, we roust
push on the catheter until it is arrested by the back of the pha-
rynx ; then turn the beak downwards, and withdraw the instru-
ment a little, until its concavity hitches against the edge of the
hard palate, and then, again making a slight sweep, and turning the
beak outwards and a little upwards, and at the same time pushing
it slightly in and out, and thus feeling for the opening, we will,
after a little practice, succeed in our attempt. We must, however,
remember that we have to deal with parts which vary in length
and caliber in diflcrent individuals. We may always be aware of

CATHBTBBI8M OF THE EUSTACHIAN TUBE. 60

the direction of the beak by looking to the ring at the end of the
catheter, as they are both on the same plane. We may now be
conscious that the instrument has acquired the desired position,
and that its beak is in the pharyngeal extremity of the Eusta-
chian tube ; but yet, until we make a further experiment with a
jet of air, we are not perfectly certain that it is in the exact posi-
tion which we desire, as the open extremity of the instrument may
be pressing against the thickened or flaccid mucous membrane of
the part. Now let us suppose that the instrument has gone in
with facility, that the patient is steady, and has a well formed
nose, and has not expressed any sign of uneasiness, — we must
not, however, let him speak, for the very act of so doing might,
until the instrument is properly flxed, disadjust its point.

There is much variety in the nasal organ, and in a great
number of instances the septum is not in the middle line : I have
met cases in which the vomer leaned over to one side, generally
the left, so that the aperture was too narrow for the passage of the
instrument ; and in other cases the lower spongy bone came down
80 low, and encroached so much upon the nasal cavity, that a
similar obstruction was produced. The chief point of irritation is
at the anterior extremity of the nose, and therefore it is, that we
must press up its point with the finger of the left hand, and also
pass the instrument with rapidity over this portion of its transit.
If the operation be properly conducted, it is, though an un-
pleasant sensation, by no means painful, and even sneezing is
seldom produced ; but there is another symptom which almost in-
variably attends the introduction of the catheter, that is, lachryma-
tion; — we constantly see a tear flowing over the cheek; it is not
the effect of pain, otherwise both eyes would weep, for it seldom
or never occurs except upon the side on which we are operating,
and it appears to be the effect of irritation of the mucous mem-
brane continuous with the conjunctiva and conveyed along the
course of the excretory lachrymal duct. It is usual to warm the
catheter by holding it near the fire, or rubbing it briskly through
the fingers ; but as the parts over which it passes are always well
lubricated with mucus, and do not grasp the instrument like the

70 APPLICATIOK OF THE AIB-FBESS.

urethra, I do not think it necessary to oil the catheter, as some re-
commend.

Having proceeded thus far, turn down the clams or forceps,
and, leaving the catheter free for a moment, grasp it with the
blades of the former, and screw home the nut which tightens them,
and tlien fix the apparatus by means of the screw which arrests
the motion of the bali-and-sockct Joint upon the forehead plate.
Upon a small table in front of the patient is placed the air-press,
the mechanism of which has been already explained, and which
had been previously charged, and to which the elastic tube,
about two feet in length, is screwed by a stop-cock communi-
cating with the receiver. To the other extremity of the tube is
fixed a small brass ferrule which fits into the end ofths catheter, in
connecting it with which considerable care and nicety is required.

The catheter being held between the finger and thumb of the left
hand, the ferrule should be delicately but firmly inserted into it
with the right. An assistant or the patient should tlien hold up
this connecting tube, lest its weight might disadjust the catheter's
point; the position of the ring at the other end of which will
always show its position. This ring should point outwards and a
little upwards, nearly on a line with the external meatus, but the
augle which it makes with the honzon, supposing the patient to

AURAL AUSCULTATION. 71

sit in a natural, erect position, will very much depend upon the
formation, and especially the length, of the external naris. The
illustration upon the previous page shows the application of the
apparatus, and serves to explain the foregoing description.

Before we apply the ear or the stethoscope to the patient*s ear,
we should partially turn the stop-cock, so as to let a little air pass
through ; for frequently, especially if the patient is at all nervous,
the first jet of air may cause him to start, and perhaps to derange the
catheter. The operator should now apply the bell'd extremity
of the stethoscope over the concha, by which means its bore is
almost directly over the external meatus; and having applied his
ear to the other end of it, he should turn the stop-cock of the
air-press with his own hand, and thereby regulate with greater
precision the force and volume of the stream of compressed air
which passes up. By this mode of manipulation alone am I
convinced of the fact of the air passing into the cavity of the
middle ear; and, until this test is applied, I do not believe that
any one can say with certainty that the air has freely passed up.

In a healthy ear, with a free tube, when a stream of air is passed
into the tympanum after this fashion, it impinges upon the inner
wall of the membrana tympani with a peculiar thug^ followed by
a continuous rustling sound, which is very remarkable, and, once
heard, is not easily forgotten. This is the natural sound, and devia-
tions from it, caused by stricture, or obstruction of the Eustachian
passage, by a diseased condition of the membrane lining the mid-
dle ear, or by collections of mucus, pus, or other fluids in that
cavity, produce abnormal sounds of a squeeling, rasping, or a gurg-
ling character, which are of value in diagnosing aural affections.
These sounds may perhaps in time be reduced to some degree of or-
der, and we should familiarize ourselves with them, so that if possible
we may be able to test and appreciate their value. Laennec was
well acquainted with the phenomena of these sounds, and anti-
cipated that auscultation would become a useful adjunct in deter-
mining not merely the condition of the Eustachian tube, but also
the state of the tympanum.

We should now place the patient in such a position that we
may have, through the ordinary tubular speculum, a clear view of

72 CATHETEBISM OF THE EUSTACHIAN TUBE.

the external surface of the membrana tympani, and we shall then
perceive, that when we permit a jet of air to reach the cavity
of the tympanum, it presses outwards the anterior and lower por-
tion of the membrane, — that which is most vibratory and placed
opposite the stream of air, — and also that it at the same time
renders the upper and posterior part of the membrane slightly
vascular.

Were we to allow too great a stream to pass through the tube,
the desired object would not be effected ; the current of air, not
able to find entrance through the Eustachian tube, would force
back and disadjust the mouth of the catheter with a loud gurgling
noise like that heard when gargling the throat, and cause consi-
derable annoyance and even pain to the patient by its regurgi-
tation. Therefore it is that the operator should with his own hand
regulate the force of the current, while at the same time he listens
to its effect upon the ear.

To remove the instrument we must proceed with the same
caution and delicacy with which we introduced it; first by gently
separating the connecting tube from the catheter ; then freeing
the latter from the blades of the vice or forceps, and, having
pulled it forward a short distance, the beak should be turned
downward and the instrument so withdrawn.

This, then, is the operation about which we have heard so
much, and from which death is said to have occurred in two in-
stances in London, some years ago. Simple and easy of perfor-
mance, however, as it now seems, I must suppose that it is occa-
sionally performed with roughness, and even violence. I remem-
ber a few years ago seeing a dragoon officer, who laboured under
raucous accumulation of the ears, and as he was himself unable to
force air into the tympanal cavity, it was deemed advisable to re-
sort to the operation which has been just described. Accordingly,
I desired an assistant to bring in the air-press, while I proceeded
to arrange the other preliminaries, merely informing the patient
that it was necessary to make an examination which would put
him to a little inconvenience, but not cause any pain. He eyed
the preparations with considerable anxiety, and at last exclaimed,
" Oh ! I know now what you are going to do, and I am deter-

THB VALUE OF EUSTACHIAN CATHETEBISM. 73

mined not to have that thing rammed up my nose again ; for the
last time it was done I was put to such pain and bled so much
that I fainted." We have known such things occur to rough and
ignorant practitioners in their endeavours to force a catheter into
the bladder, and the mention of this circumstance is, I feel, suffi-
cient to put us on our guard; and I think I need scarcely add,
that, where such force and violence as that detailed by this gen-
tleman were employed, the original object of the operation could
not have been attained.

We have all heard a great deal about catheterism of the Eus-
tachian tube— of the marvellous and instantaneous effects attri-
buted thereto, of the accidents which may occur, and of the diffi-
culties which beset the operator in his endeavour to introduce an
instrument into the faucial opening of the passage which leads
into the middle ear. I know few subjects upon which there is
more general ignorance than the value to be attached to Eusta-
chian catheterism, or the best mode of employing it. Some wri-
ters would lead us to suppose that this operation is of use in a far
greater number of aural diseases than, according to my experience,
is the fisu^t. In order to facilitate our diagnosis, they would have
us explore the middle ear by the air douchey a jet of water, or
a solid instrument, in almost every case that presents. Errors
of commission are, in both medicine and surgery, I believe,
of much greater injury than those of omission ; and theintroduc-
tion of a foreign body into the Eustachian tube, forcing a volume
of cold air, or injecting a quantity of fluid, even warm water,
into the cavity of the middle ear, as some recommend and say they
practise, is, in nearly all cases, while inflammatory action is going
forward in the parts submitted to the process, unnecessary and fre-
quently injurious. Again, the mode in which I have heard both
patients and bystanders speak of instruments — catheters of various
kinds, gum-elastic, and metallic, and even solid sounds, some of
the latter much larger than the bore of the aural end of the Eus-
tachian tube even in the dry bone — being introduced into the
middle ear, in order to explore that cavity, to wash out its con-
tents, or to break up collections of mucus within it, or to dilate
strictures and contractions of the tube itself, convinces me that

74 THE EUSTACHIAN BOUGIE.

the desired object was not, fortunately for the sufferers, obtained.
Even Kramer speaks of pushing a catgut bougie, introduced
through the Eustachian tube, " between the handle of the malleus
and the incus" ! People are, however, beginning to find that this
attempt — for I know in many cases it is only an attempt — to
force solid or fluid substances into the cavity of the drum, is as in-
effectual to remove deafness as the almost indiscriminate excision
of the tonsils — since preserved in pickle-pots — recommended for a
like purpose a few years ago, has proved to be. I have heard of
cases in which the middle ear has been said to be explored by
such mechanical means, even in this country, and I have been
shown steel sounds manufactured for the purpose. Such instru-
ments are, however, with the exception of the tearing and in-
flammation which they may cause in the nasal extremity of the
tube, harmless, for they could not by any possibility, even in the
dead subject, be passed through the upper end of the Eustachian
tube. We should bear this rule ever in remembrance before ex-
ploring the middle ear ; it is one which Sir A. Cooper observed
to me many years ago, and I have ever since acted upon it : —
Whenever the patient is himself able to inflate the tympanum, never
use any artificial means to do so ; it is unnecessary and may be
injurious. Let me to this aphorism add another, to which I have
already alluded, and which surgeons would do well to remember.
Where there is reason to believe that the cavity of the drum is
inflamed, carefully abstain from all poking with catheters, or any
attempt to introduce foreign substances into that delicately-orga-
nized portion of the animal machine. As good general surgery
teaches us to avoid the introduction of instruments through an
inflamed urethra, or into an irritable bladder, so ought judicious
aural surgery teach us to abstain from meddling in the cases to
which I have alluded. The only solid instrument with which I
now ever venture to explore the Eustachian passage, and that
for only a short distance, is an ivory bougie, rendered flexible by
having the earthy matter removed by immersion in an acid, and
the point of which for an inch at least had been previously sof-
tened in water so as to resemble apiece of gelatine. A large-sized
catheter should be first introduced, and the bougie passed up

IHJBCTI0N8 AND FUMIGATIONS OF THE TYMPANUM. 75

through it; but stricture of the Eustachian tube is so exceedingly
rare, and so difficult to recognise during life, that the surgeon is
very seldom called on to practise such an operation.

In connexion with Eustachian catheterism should be men-
tioned, the mode of injecting fluids for the purpose of washing
out the tube and the middle ear, in case of impaction of the
former, or mucous accumulation in the latter ; and of intro-
ducing gases, etherous vapours, resinous and other volatile sub-
stances, for the purpose of altering the condition of the mucous
membrane, or stimulating the nervous expansion on its sur-
face. A simple elastic bag, with the nozzle adapted to the end of
the catheter, will, for those who may be inclined to practise it^
effect all that is required or that can be attained by syringing out
the tympanum : in general I believe the fluid seldom reaches that
point, while it causes great irritation by regurgitating into the
throat; but in order that it may have a fair chance of going into
the middle ear, the catheter ought to be fixed by the frontlet
as already described. Supposing we may with safety explore the
Eustachian tube, and endeavour by artificial means to press a
column of air or a jet of fluid into the middle ear, and thereby
free it of its extraneous contents, and restore to its natural posi-
tion the vibrating portion of the tympanal membrane, it will be
of little avail to effect these objects, — as it would be merely to press
out the contents of the lachrymal sac in a case of mucocele, or
chronic inflammation of the mucous membrane of that cavity, —
\mless we at the same time make use of such means, both topically
and constitutionally, as shall restore the healthy character of the
lining membrane, which evidently participates in the diseased
action, and of which manifest traces are observable upon the ex-
ternal aspect of the membrana tympani.

For vaporizing the tympanum a variety of ingenious contri-
vances have been invented, especially by the continental aurists,
consisting of air-tight jars containing gas, connected with the ca-
theter by elastic tubes, or vessels shaped like retorts, in which the
substances to be vaporized are placed, fixed upon the ordinary
chemical stands over spirit-lamps. These shall be more particu-

76 BTRUlalHG.

Urly considered in the section relating to "nervous deafness,"
the disease for which such fumigations arc said to be applicable.

In the previous description of the method of examining the
external and middle ear it has been prcsumod that the external
ftuditory conduit is free ; it may, however, and it often does, hap-
pen, that we are unable to explore the passage, or obtain a view
of the membrana tjmpani, owing to obstruction of the former
with cerumen, collections of hur, or thickened and detached epi-
thelium, the muco-purulent secretion consequent upon otorrhcca,
or foreign bodies of any description ; and therefore it is sometimes
necessary to have recourse to the operation of syringing merely
to assist our dit^nosis. Simple as this operation may appear, and
frequently as it ia resorted to by uneducated persons, it is one
which requires some degree of tact, caution, and dexterity, in its
performance.

To avoid slopping in syringing the ears, I have found the
form of vessel represented below very useful: it is metallic, six
inches long, four broad, and two deep ; its concave part Gts accu-
rately the curve beneath the lobe of the ear, and the perforated
septum strains the clean water from the dirty. If held by the
patient in the proper position, closely applied to the cheek, no
water can get down by its side.

The top of the auricle should be grasped with the left hand,
and drawn slightly upwards, outwards, and forwards, so as to
assist in straightening the auditory canal; and then we can inject

PHEKOMBNA ATTBNBma SYBINGIKG. 77

B Steady stream of water, the thumb raising and depressing the
piston by means of a brass syringe, capable of holding three or four
ounces of fluid, but so constructed, as shown in the accompany-
ing cut, — with a pair of loops attached to its upper extremity,
through which the fore and middle fingers are passed, — that it
may be worked with facility by the right hand.

This instrument is, however, only suited to the hands of a
surgeon. The small pewter, bone, and glass syringes are really
of little or no use. The gum-elastic bag is the safest for general
use ; but I do not think it possible for any one effectually to
syringe his own ear.

In some persons, syringing, or the mere introduction of a spe-
culum, induces violent paroxysms of coughing ; in others, the
simple act of injecting tepid water will produce syncope, although
such patients tell us that it is not from the pain they feel. The
removal of a granulation, or a small polypus from the external
auditory passage, will at times produce sickness of stomach, weak-
ness, and even fainting.

There is a circumstance connected with this part of the aural
examination worthy of attention. We often observe that, during
the removal of wax, in syringing or in any way interfering with
the meatus, the patient is seized with a fit of spasmodic coughing,
apparently caused by some irritation in the larynx, and we can
reproduce the phenomenon simply by the introduction of a probe,
and touching ever so gently a particular spot upon the surface
of the meatus. This is not a very unusual phenomenon, al-
though it cannot be produced in all cases. I never witnessed it
in children or very young persons ; it is most common in males of
about middle life, and is in nowise connected with any previous
disease existing in the respiratory apparatus. In some persons the

78 THB PBACTICES OF PROBING AND STRINGING.

slightest touch of the floor of the external auditory passage, about
midway between its external outlet and the inferior attachment of
the membrana tympani, will bring on violent irritation and spas-
modic action in the larynx. In this case also the patient will
generally tell us, upon inquiry, that he does not experience pain ;
but that the moment we touch this very sensitive spot he feels a
tickling sensation in his throat, which immediately increases to
the feeling one has when ** a bit is gone astray." What the ner-
vous connexion may be which induces this has not been fully de-
termined, but the fact is worthy of note. The different degrees
of sensibility of the several parts of the external ear are worthy
of remark. For further particulars on this point, and also as re-
regards syringing, see the section on Cerumen in Chapter iv.

The effort of coughing, sneezing, blowing the nose, and de-
glutition, in causing or increasing pain, is also to be particularly
attended to, if we suspect inflammation in the drum or the Kusta-
ohian tube.

There are two methods of examining the ear, on which, from
their frequency in this country, I am induced to make some re-
marks, in the hope of putting a stop to practices not only useless,
but in some cases positively injurious. I allude to the common
habit of syringing indiscriminately, and also of probing the
ears, without proper inspection of the parts. The former is of
daily occurrence; thus a patient labouring under deafness, or,
what perhaps is worse, violent pain in the ear, is examined either
without the assistance of a speculum, or by means of some oF the
old divaricating instruments, most probably in a badly-lighted
apartment, — at all events, without the membrana tympani being
brought into view, a dark cavity being all that the explorer is
able to perceive; — it is deemed advisable to try what might
come out by squirting hot water into this dark passage for a
quarter of an hour or longer ; but, nothing satisfactory following
this operation, the diagnosis that there is no wax in the ear is ac-
cordingly made. Now, there may be a collection of cerumen,
which may not be got rid of by this operation ; while, if the cause
of the pain or deafness is owing to an inflammatory condition of
the auditory canal and its membranous extremity, a decided in-

THE HEABINO DISTANCE. 79

crease of the symptoms is induced by this useless and cruel pro-
ceeding : and I have frequently seen inflammation produced by
unnecessarily syringing an ear where no wax was present.

The practice of exploring the ear by means of a probe I can-
not too strongly condemn, and yet that it is frequently resorted to
surgeons are well aware. To introduce a common dressing probe
and press it against the membrana tympani, without having that
membrane fairly within view, and without a speculum being
introduced, but merely for the purpose of satisfying the examiner
as to whether the membrane is perforate or not, is, I think, a
most unjustifiable proceeding.

The degree of deafness may be learned, and the hearing dis-
tance measured, by holding an ordinary watch near the external
meatus, and the distance at which the tickings can be accurately
counted, and at which the patient is conscious of an interval be-
tween these sounds, should be recorded. To effect this properly,
the watch should be approached gradually to the ear till it gets
within the hearing point, and again applied directly to the auricle,
and gradually removed to some distance. Various instruments,
producing a ticking sound by means of clockwork, have been in-
vented, by Schmalz and others, for this purpose, but the watch is
quite sufficient. We should also test the hearing with the mouth
open as well as shut ; and it should be tried both before and after
the inflation of the tympanum, as in many cases that act will
produce a very material difference in the amount of hearing.
The watch should next be applied both behind and in front of
the auricle, and to the forehead, and also placed gently between
the teeth of the patient, and the amount of hearing thus obtained
likewise noted. It is absolutely necessary, if we wish to watch
the progress of a case, not only to conduct these observations with
great care, but also to take a written note of the *' hearing distance"*
the first and each subsequent time we see the patient. By this
means we have the most satisfactory report of the progress of the
case, both for ourselves and the patient. It must be remembered
that there is almost as great a difiference in the normal hearing
as there is in the normal seeing distance, even among persons
who have never laboured under any disease of the ear, and who

80 EXAMINATION OF TUB THROAT AND NOSE.

are not at all conscious of any defect of hearing. The degree of
hearing with a watch is sometimes deceptive ; some patients who
cannot hear a watch, or even a clock, will hear the voice, even in
a low tone ; but these are the exceptions to the rule. Except in
cases of congenital or acquired deaf-dumbness, total deafness is a
rare affection, much more so than total blindness ; and great variety
exists with respect to the amount of hearing lost, and how the
defect is described, as, for instance, hardness of hearing, short
hearing, dulness of hearing, &c.

While inquiring into the amount of deafness, and the circum-
stances under which the hearing is increased or diminished, wc
should learn whether it be improved or not when the patient is
exposed to loud noises, as when standing in a mill, walking
through a crowded street, or travelling in a carriage or on a rail-
way. We should also inquire whether the hearing is better at one
time of the day than another, and abo whether it is increased or
lessened after meals, particularly dinner.

The condition of the throaty the arches of the palate, uvula,
tonsils, and back of the pharynx, should next be inquired into,
particularly as regards the state of the mucous membrane, its
colour, turgescence, or degree of relaxation ; likewise the state of
infiltration of the submucous tissue. The forefinger should then
be introduced far into the mouth, and its point made to press
firmly upwards and outwards beyond the arch of the palate, op-
posite the mouth of the Eustachian tube, and notice taken of the
degree of pain or inconvenience it produces there and in the
middle ear. We should also carefully examine the state of the
membrane of the nose, for which purpose the little instrument
figured at page 55 will be found useful.

Something may be gleaned from the character of the wice,
as few instances occur of intense or long-continued deafness with-
out that function exhibiting manifest symptoms of the defect of
hearing to a greater or less extent. This defect does not seem to
be produced by any visible alteration in the parts engaged in the
mechanism of speech ; it often takes place without any enlarge-
ment of the tonsils, elongation of the uvula, or other abnormal
condition of the throat, larynx, or mouth. There is a peculiarity

CHABACTBB OF THE VOICE. 81

of voice and speech attendant upon deafness approaching some-
what to the condition and character of articulation which the
deaf-mute educated according to the vocal system presents, and
which once heard is seldom forgotten. The voice, from not being
perfectly heard by the patient himself, loses its sonorous intonation,
and becomes hoarse and inharmonious, or harsh and husky, with a
metallic twang. In time the patient loses the power of modula-
tion, and often appears to labour under that defect, commonly,
though incorrectly, denominated speaking through the nose.
Such persons generally express themselves in an unnecessarily
loud tone; they speak as if they were out of breath, and there
is a sort of whistling sound in the speech as if the air was sipped
in through the mouth, and then blown out through the nose ;
and in the advanced stage, particularly if the disease commenced
in youth, the utterance becomes indistinct. Such cases are gene-
rally most unfavourable, and I make it a rule to inform the pa-
tient or his friends of my suspicions, even before I institute an exa-
mination, as this symptom is always indicative of long-continued
dulness of hearing. If the patient is a person of intelligence we
generally find that he anxiously and intently watches the motions
of the lips of the person by whom he is addressed, in order to aa*
ttst him in making out what is said. I know several persons who
can understand what is addressed to them by their friends, or
those to whom they are accustomed, simply by observing the mo-
tions of the lips. The works describing the mode of teaching
articulation to the deaf and dumb may be read with advantage on
the subject.

Persons with <^ musical ears** have remarked to me that they
first became aware of the approach of deafness by not being able
to distinguish one octave from another; yet in many instances the
musical ear remains unimpaired though general hearing is much
afifected.

I have thus described the routine of examination that will be
found most practically useful. Having proceeded thus far, we may
inquire into the history of the disease, its duration, assigned cause,
the pain, noise, the probable hereditary nature of the complaint,
Ac., and hear the subjective symptoms, in the usual manner in

G

82 TINNITUS AURIUM.

which we would proceed to examine any other medical or surgical
case. There are, however, a few inquiries which should be par-
ticularly made, especially as to .the existence of iinnitua aurium;
and, if such be present, what are the peculiar characters of it;
how many kinds of noises are experienced ; whether they are
permanent or intermitting; under what circumstances they are
decreased or diminished ; and, above all, whether the patient re-
fers them to the ears or to the interior of the head ; and whether
one or both ears are equally affected by them.

The value of tinnitus as a diagnostic has been greatly over-
rated. It is certainly one of the most distressing as well as the
most frequent symptoms attendant upon affections of the organs
of hearing, but its cause is very obscure and difficult to compre-
hend, and its removal still more difficult to achieve. I know no
symptom concerning which a more cautious prognosis should be
given, as it is one common to almost all, and peculiar to none, of
the diseases of the ear. Like muscse volitantes in the eye, it may
exist as an isolated symptom, or it may be an attendant upon se-
veral aural diseases. It is often caused by cerebral disease ; there-
fore we should carefully inquire whether it is felt in the head or
in one or both ears ; it is sometimes an accompaniment of derange-
ment of the circulating, digestive, or uterine organs; of congestion
of the brain, haemorrhage, hypochondria, hysteria, chlorosis, anae-
mia, typhus, influenza, or simple catarrh ; of closure of the external
meatus, obstruction of the Eustachian tube, and impaction of the
auditory passage with wax ; a foreign body, or even a hair resting
on the tympanal membrane, as well as engorgement of the lining
membrane, or mucous collections in the tympanal cavity, and
also nervous deafness, will all produce it. Furthermore, we may
remove the original disease, give a healthy action to the affected
organ, and restore its function, — yet will the noise remain. It is
always most felt at night when the patient lies down to rest; it is
least experienced in the open air, in a crowd, or when travelling
in a carriage. It seldom or never co-exists with an open tym-
panal membrane, and, therefore, perforation of the drum has
been resorted to, and occasionally with effect, to relieve patients
of this distressing malady. In cases of complete acquired deaf-

TINNITUS AUBIUM. 83

muteism it is not present. So great is the discomfort which it
gives, that persons incurably deaf, and who are quite conscious
of the impossibily of restoring their hearing, will still apply to be
relieved from this haunting and most annoying symptom ; and
therefore it is, that, in the quack advertisements, we always read
of the "promise to cure ringings and noises in the ears." The
peculiar characters of the tinnitus, and the noises to which it is
likened, are as variable as sound itself. Do these characters de-
pend upon the cause of the deafness, or the portions of the organs
affected ? I have taken some pains to investigate the subject, and
I believe not. They are no more dependent upon the causes of
the disease, nor the structures engaged, than the peculiar form
which ocular spectra and motes floating before the eyes are conr
tingent upon the parts concerned in ophthalmic or cerebral dis-
eases. No one has yet been able to arrange or classify the pecu-
liar description of muscae contingent upon congestion, amaurosis,
choroid disease, cataract, or disease of the brain or its membranes;
no more than they can satisfactorily account for both muscse and
" noises in the ears" in cases of hasmorrhage.

I think the descriptions which patients give of the noise which
they experience depend, to a certain degree, upon their fancy, their
graphic powers of explanation, and not unfrequently upon their
rank of life, or the position in which they have been placed, and
the sounds with which they are most familiar: thus, persons from
the country or rural districts draw their similitudes from the objects
and noises by which they have been surrounded, as the falling
and rushing of water, the singing of birds, buzzing of bees, and
the waving or rustling of trees ; while, on the other hand, persons
living in towns, or in the vicinity of machinery or manufactureSi
say that they hear the rolling of carriages, hammerings, and the
various noises caused by steam-engines. Servants almost inva-
riably add to their other complaints, that they suffer from " the
ringing of bells" in their ears ; while in this country, old women
much given to tea-drinking sum up the category of their ail-
ments by saying, that " all the kettles in Ireland are boiling in
their ears." The tidal sound, or that which we can produce by

o2

84 CAU8R8 OF TINNITUS.

holding a conch-shell to the ear, is, however, what is most fre-
quently complained of. Sometimes the tinnitus exists as an iso-
lated symptom ; but in several such cases I have remarked, that
sooner or later either aural or cerebral disease manifested itself.
Removing the cause and curing the deafness will often, but not
always, relieve the patient of the noise.

The causes of tinnitus — for they must be many — are never
likely to be fully explained ; and morbid anatomy holds out but
little hope of clearing up the mystery attending the production of
noises in either the ears or head. From its not being present
where the membrana tympani has been in whole or in part re-
moved, and that hearing is not quite destroyed, and from its ces-
sation after artificial perforation on the one hand ; and, as we have
all experienced its occasional presence in influenza, sore throat, or
simple catarrh, until by pressing air through the Eustachian tube
into the tympanal cavity, we instantaneously get rid of it, — on the
other ; I am firmly of opinion that one cause of tinnitus is a non*
vibratability of the membrana tympani. All cases of closure of
the Eustachian tube, of collapse of the membrana tympani, as well
as, in most instances, of accumulations in the middle ear, are
attended by this symptom. Kramer formerly thought that his
so-called nervous deafness might be divided into the erethetic, or
that attended with tinnitus — generally incurable — and the torpid,
or that without tinnitus, said to be relieved by fumigation I He
has, however, subsequently relinquished this fanciful and hypo-
thetical division. Laennec considered tinnitus as an acoustic illu-
sion ; but buzzing in the ear might, he thought, depend on spas-
modic contraction of the muscles of the ossicles. This latter
theory, though unsustained by any fact, serves to support the
hypothesis of the want of vibrating power in the membrana tym-
pani being one cause of tinnitus; possibly a similar state of the
membrane of the fenestra rotunda may be another.

Physicians are too much in the habit of treating patients for
this symptom alone, without having made a careful examination
of the ears. I have seen persons who had been subjected to a se-
vere course of treatment, consisting of cupping and leeching, low
diet, blistering the nape of the neck, purgation, salivation, or the

THB APPLICATION OF BBMEDIE8 — LEECHING. 85

administration of blue pill and James's powder, for noises in the
ears and head, until it was eventually discovered that all their
symptoms proceeded from a comparatively thin cake of hardened
wax pressing on the drum of the ear.

Inquiries as to the general health of the patient, the due per-
formance of all the functions, and the endeavour to ascertain how
much of the disease is purely local, or dependent upon some con-
stitutional affection, will, no doubt, be made by every educated
physician or surgeon, so that it is unnecessary here to call special
attention to these circumstances.

By the foregoing method of examination and observation of
the physical signs, and an attention to the rules which I have en-
deavoured to lay down, we ought in almost every case be able to
form a tolerably accurate diagnosis.

As much ignorance prevails with respect to the mode of ap-
plying even the ordinary remedies employed in aural affections,
a few remarks thereon may not be out of place, before entering
upon a description of the cases to which they are applicable. As
most of the diseases of the organs of hearing are originally of an
inflammatory character, depletion is strictly enjoined; I have,
however, seldom found it necessary to resort to general bleeding ;
but local depletion is imperatively required, either by cupping or
by leeches. The former method is not easily managed so near
the part affected as to be of much service ; but in cases of very
severe otitis, it may be had recourse to, and a dexterous cupper
will with a small instrument take several ounces of blood from
the soft parts immediately behind and beneath the mastoid pro-
cess; and if the head be much engaged, blood may also be ab-
stracted by the same means from the nape of the neck. Leeches
are, however, the most effectual means of abstracting blood and
relieving pain in all such cases ; but they should not be applied
in the manner heretofore employed behind the mastoid process:
to be of service they must be attached with a small bevil-mouthed
leech-glass immediately around and within the edge of the exter-
nal meatus, in the fossa behind the tragus, and, if necessary, in
front of that prominence, in the hollow formed by depressing the
jaw. From four to six leeches may be readily attached round the

86 LBECHnro.

meatus, and in this situation they will produce more immediate
and permanent relief than three times the nnmber affixed behind
the auricle. The application in front of the tragus is also very
much more effectual than upon the mastoid region. When, how-
ever, the latter locality becomes itself the seat of inflammatory
action, they should also be applied freely all over it. Where we
have already recently applied leeches in the two first-mentioned
places, and that the parts have thereby become swollen and ir-
ritated, the next most advantageous position is beneath the lobe
of the auricle, behind the ramus of the jaw. I do not know any
painful affection in which leeches applied in the manner directed
produce the same amount of immediate relief, as in disease of
the ear. They should be had recourse to again and again, even
upon the same day, and applied in numbers, to relieve paroxysms
of pain, as well as to lessen the degree of redness and vascularity
observable in the inflamed parts.

Unless in cases of violent otitis, heretofore leeches were sel-
dom used to relieve aural diseases, because the practitioner,
not being acquainted with the nature or seat of the majority of
these affections, and not possessing the means or knowledge ca-
pable of effecting a proper inspection of the parts engaged,
seldom made an accurate diagnosis. He worked in the dark, and
prescribed at random, more frequently than when treating any
other class of diseases, no matter how obscure; and hence the
opprobrious epithets which the public, and even many of the
profession, applied to the treatment of diseases of the ear. Such
observations were, however, just as applicable to the treatment of
diseases of the uterus and vagina until the introduction of the
speculum into modern practice. As the space to which leeches
can be applied is limited, and as it is often a tedious and trouble-
some operation, it requires some care and dexterity in its manage-
ment. I generally mark the places where they may be applied
with spots of ink, in order that the apothecary may not make any
mistake ; for, if this is not done, we sometimes find that the
leeches have been allowed to attach themselves to the cavity of
the concha, or other places on the auricle, where they are of no
use, and often give rise to much irritation, oedema, and even ery-

LBBCHIHO. 87

sipelas. The external meatus should first be filled with a bit of
cotton wool, to a level with the external aperture, not so much
for the purpose of preventing the leeches going in too far, as to
exclude the blood, which is very likely to flow back and accu-
mulate at the bottom of the meatus auditorius extemus, coagulat-
ing and crusting over the surface of the tympanal membranOi
thereby causing much annoyance to the patient, and even an ag«
gravation of his symptoms. The posterior lip of the external
aperture afibrds the largest and most convenient surface for the ap-
plication of leeches, and in an adult, three may always be attached
thereto with facility. The anterior lip, being more concealed and
slightly concave, cannot so well be got at, yet two may generally
be applied there. The next best part to which to apply them is
the depression in front of the tragus, immediately below the infe-
rior root of the zygoma, where in aural inflammations the patient
is so frequently susceptible of pain upon the least pressure, and
there, six or eight may be applied if necessary.

As leech-bites on any of those places which I have mentioned
continue to bleed freely for a long time, the person employed to
apply the leeches should be directed to stop them as soon as the
proper quantity of blood has been removed, either by the applica-
tion of lunar caustic, or any of the most approved means for this
purpose ; but it is necessary that we should be aware of the fact,
that the haemorrhage from leech-bites on these parts is more
ikely to continue than elsewhere. The leech-bites do not cause
xtravasation and blackening of the auricle as they so frequently
0 the parts about the eye ; but they often give rise to erysipelatous
flammation, and therefore in all such cases the idiosyncrasy of
e patient in this matter should be previously inquired into. I
ow a gentleman with a remarkably dry skin, who labours un*
* chronic inflammation of the membrana tympani and the mu-
8 lining of the middle ear, who is so susceptible in this respect
. the application of a single leech will invariably produce ery-
lasofthe side of the head and face. The cotton with which
vuditory passage is stufled, and the external portion of which
ys becomes saturated with the blood, should not be removed
the oozing from the leech-bites has quite ceased.

88 COUVTBB-IRBITATIOV.

With respect to counter-irritation : — ^in acute cases, common fly
blisters are the most convenient and effectual method ; but as the
space uncovered by hair over which they can be applied behind
the auricle is limited, they should not have the usual adhesive
margin on the inner concave edge, and they should be spread on
fine leather, that they may fit closely over the irregular surface to
which they are applied. If it is desirable to keep the blister open,
or to establish an issue, it can easily be effected by removing the
cuticle and dressing the raw surface with Albespeyrre*s plaster, the
most convenient spot for which is immediately behind the lobe,
and beneath the mastoid protuberance. It is, however, especially
in the male sex, difficult to retain such means in that locality with-
out a bandage.

In old chronic cases, where the disease is of long standing,
and there is much thickening of the membrana tympani, I have
found that the pustules produced by the application of tartar
emetic ointment are the most effectual method. A small quantity
of the ointment should be rubbed once or twice a day to all that
part of the mastoid region which is not covered by hair, — care
being taken not to let the ointment spread over the back of the
auricle, where it would produce very angry and irritable sores, —
until a copious eruption is produced. A bit of soft; linen should
be applied between the auricle and the surface submitted to the
action of the remedy. As soon as the pustules are fully deve-
loped the application should be discontinued, and the part al-
lowed to heal perfectly before it is resumed. To be effectual,
however, this remedy must be continued for several weeks, or
even months. As it is not always possible to measure or control
its action, a poultice should be applied occasionally when the pus-
tules spread, or seem inclined to coalesce.

The usual rubefacient and vesicating liniments must be used
with caution when applied to the mastoid region, as their action
is very apt to spread over the back of the auricle, and cause con*
siderable swelling and irritation thereof I have on several occa-
sions seen the eruption caused by croton oil extend from the mas-
toid region not only over the external ear, but to the side of the
face, and produce oedema, redness, and intense itching of the eye-

LINIMBNT8, FOMENTATIONS^ DROPS, ETC. 89

lids. Where there is much neuralgic pain complained of, ex-
tending from the ear over the side and back of the head, I have
found the compound camphor liniment, with extract of bella-
donna, one of the most useful applications ; but in this preparation
care should be taken to rub the belladonna first with a little wa-
ter in a mortar, otherwise it will not mix with the liniment. In
children and young persons the strong tincture of iodine, contain-
ing some iodide of potassium, is a very useful remedy, and pro-
bably acts specifically as well as a stimulant ; it should be applied
with a camel-hair pencil daily, or every second day, unless the
parts begin to vesicate or the cuticle to peel ofif, when the applica-
tion should be discontinued for a few days. The use of iodine,
however, by the edermic method is only of value by being long per-
sisted in. Indeed the same may be said of most irritants, — to be
effective they must be continued for a great length of time, long
before the expiration of which, in many cases, both the patient
and the practitioner are tired of each other.

The application of lieat and moisture is particularly grateful ;
steaming the ear by holding it over the vapour of some very hot
water placed at the bottom of a long, narrow vessel, medicated
with hyoscyamus, opium, belladonna, or with the ordinary decoc-
tion of marsh-mallows, camomile, or poppy-heads, gives great com-
fort The Russians employ a peculiar apparatus for relieving
pain in the ear, consisting of a funnel-shaped roll of linen, the
small end of which is applied to the meatus, while the large end,
in which various balsamic substances are placed and set fire to,
is allowed to burn down slowly like a moxa. A warm linseed-
meal poultice, renewed every two or three hours, gives great relief.
Stupes and fomentations are not as efficacious in aural as in oph-
thalmic inflammations.

Under no circumstances should wo pour any stimulating or
sedative liquors into the ear. From the firequency of this most
unjustifiable practice in this country, I feel I cannot too strongly
deprecate it. If there is one substance more irritating than ano-
ther in the Pharmacopoeia, it is poured, secundum artem^ into the
ear, to relieve pain, or cure dea&ess, to lessen or to increase the
secreUon of wax I This practice is often the cause of myringitis.

90 GALYANISM AND BLECTBICITT.

Why are not these essential oils, stimulating liniments, this tur-
pentine, creasote, tincture of cantharides, oil of origanum, &c.,
poured into the eye, or injected into the urethra, in cases of in-
flammation of these parts ? Why do not surgeons prescribe a
roasted onion, or a boiled fig, for inflammations of other parts as
well as the ear?

I have no faith in either electro-magnetism, galvanism, or
electricity, in relieving deafness. I never knew a case which had
proved unamenable to other treatment cured by any of these
means. True it is we read in the periodicals from year to year
of cures effected by such agents, but for the most part they are
unauthenticated, and in all, there is in the description of symp-
toms and the diagnosis a manifest want of knowledge on the sub-
ject of aural medicine and surgery. How would the profession
receive an account of a " cure of blindness by electro-galvanism,"
without being informed what had been the cause of such loss of
sight ? However, as I believe the great mass of aural diseases are
the products of inflammation in some form or other, it is obvious
that such agents can effect little for their removal. Even sup-
posing the auditory nerve to be the seat of the disease, and that a
true cophosis, the analogue to amaurosis, is present, it may be
asked, how few uncomplicated cases of the latter, of simple func-
tional impairment or insensibility of the retina or optic nerve,
without any cerebral lesion, do we meet with ? and how still
fewer do we remember being cured or relieved by electricity or
galvanism ? It is therefore unnecessary to describe the various
ingenious machines which have been invented, and are described
in books, for applying these means to the Eustachian tube, and
the external surface of the tympanal membrane.

Mercury is the medicine which of all others acts most bene-
ficially in diseases of the ears, simply on account of its specific
efficacy in arresting or controlling inflammation or removing
its products. But as there are a variety of aural affections to
which it is applicable, so are there a variety of modes of adminis-
tering this powerful mineral, and a diversity of preparations, each
specially apposite to the particular stage of disease, the class of
symptoms, or the peculiar habits and constitution of the patient.

HERCUBT. 91

A well-educated surgeon, experienced in the administration of
mercury, and with general and enlarged views both as to the ac-
tion of medicine and disease, will, no doubt, suit the remedy to
the particular case ; but as a rule I may remark, that the modes
of exhibiting it in ocular affections will serve as a safe guide for
giving it in diseases of the organ of hearing. In the more vio-
lent inflammations of the fibrous structure of the membrana tym-
pani, the periosteal lining of the cavity of the tympanum, the Eusta-
chian tube, or the deeper portion of the external meatus, and also
the inflammations of the internal ear, when such can be diagnosed,
as well as the specific inflammations of a rheumatic or syphilitic
character, where actual ptyalism is indicated, we must introduce
it quickly, and in such doses as will bring the system under its
influence at once, just as we would in inflammations of analo-
gous tissues in the eye, the envelopes of bones, or the membranes
investing the joints or any of the great cavities of the body. In
such cases small and frequently repeated doses of blue pill and calo-
mel, with opium, will most speedily produce the desired efiect,
provided the well-known rules for the administration of mercury
are attended to. I do not think, however, that students attend
sufficiently to the symptoms and appearances produced by mer-
cury on the mouth. Among the lower orders, or with hospital
patients, the over-action of mercury upon his patient seldom gives
the practitioner much uneasiness ; but in private practice it is very
different. There is a general horror of mercury among the middle
and upper ranks ; and the prejudices and superstitions which exist
on the subject, with respect to the mischief it does to the constitu-
tion, and the difficulty of ** getting it out of the boncs,^ are still as
rife among some classes as when a distinguished and titled senator
swore, at the trial of St. John Long, that he saw the mercury which
had been taken many years before appear in globules of pure quick-
silver upon the forehead of a nobleman, drawn forth by the effi-
cacy of the sponge and liniment of the redoubted curer of con-
sumption ! The effect of mercury upon the constitution, as well
as upon disease, is most variable. With some the slightest quan-
tity will, unless carefully watched, produce salivation ; while other
persons seem totally unsusceptible of its influence. The abuse,

92 MBRCUBT.

however, which one comes in for in practice, because a patient has
suddenly got a very sore mouth, should be borne with philosophic
indifference ; as although the effect is in excess, the desired result
has been obtained. Some ladies, however, will fret about the da-
mage likely to be done to their teeth, more than they did for the
disease for which the mercury was given ; and many patients,
who greedily learn all the symptoms of its action, will complain
of sore mouths, spongy gums, aching teeth, &c., when, in reality,
it is impossible to affect them.

Few of us now witness what mercury can do when allowed
ts full swing, or when pressed to the extent which it was some
twenty or thirty years ago. Very few of us have now an oppor-
tunity, I am happy to say, of witnessing many cases of mercurial
erythema, or the prostration of ery thismus, or seeing every tooth
in a patient's head shaking, and streams of saliva pouring from his
mouth, from the long-continued use of the mineral, — when the
wards of an hospital were, from the quantity of mercury used, both
internally and externally , by pill-taking, skin-rubbing, plasters, and
fumigation, rendered mercurial baths, in which the vapour of fetid
breaths contended with the stench of sloughing ulcers, and the
effluvia resulting from mercurial diarrhoea. Such times and scenes
have passed, and the public and the profession have reason to re-
joice thereat. Practitioners are now satisfied with the mild ex-
hibition of mercury, and deem it more prudent to keep up a
gentle action for some time than to allow profuse salivation to
occur. Yet, notwithstanding all this, cases will happen the re-
verse of the unsusceptible, in which the mineral acts suddenly
and violently, and its effects are scarcely within control. This
will occur occasionally in peculiar constitutions, where there is
a special idiosyncrasy. Profuse salivation raj^idly sets in, the
glands of the neck enlarge, the mucous membrane of the throat
and inside of the mouth runs rapidly into ulceration, and the
tongue swells to an alarming extent, so as to resemble a case of
glossitis, but it is white, slimy, and looks like a piece of mace-
rated liver, and it not uncommonly protrudes between the teeth.
The most alarming symptoms occasionally follow, and in one in-
stance death occiurred, in this city, some years ago, from swelling

MEBCURT. 93

of the tongue in the manner which I described, and as the result
of sudden and uncontrollable mercurial action. Sometimes the
cheeks and other parts of the face swell to a great extent. It is
scarcely necessary to state, that deglutition and respiration must
be considerably impaired under such a state of things. Among
the remarkable effects of mercury which I have seen, I may men-
tion the instance of a lady who once consulted me on account of
.profuse salivation which had continued for five years.

Now it is, as I already observed, because I do not think stu-
dents attend sufficiently to the appearances which mercury pre-
sents in the mouth, and also because cases of excessive mercurial
action must occasionally occur in large public institutions, where
it is absolutely necessary to give mercury to external patients,
many of whom are either careless and indifferent about them-
selves, or are, from their domestic circumstances, more than ordi-
narily exposed to the vicissitudes of the weather, that I wish par-
ticularly to draw attention to the earlier and milder symptoms
of mercurial action. The fetor of the breath is a variable sign,
although when present it is an unfailing indication ; but it is sel-
dom commensurate with the amount of mercurial action. Some-
times the breath is naturally heavy, or even fetid, and then it is
difficult to distinguish the one from the other. There is a pe-
culiar heavy breath belonging to strumous patients, which it is
difficult to describe, but which, once perceived, is easily recog-
nised ever after. I may here mention, that I do not remember a
single instance in which, for any cause, mercurial action was fully
produced in a person possessing naturally what is termed *'bad
breath,** that that most unpleasant affection was not removed by
it. There is often some swelling of the gum behind the last
molar tooth of the lower jaw ; this I look upon as an almost in-
variable symptom, and sometimes it is the only one which can be
produced. The mucous membrane between the tooth and the
angle of the jaw swells and overlaps the tooth, rendering masti-
cation very unpleasant, and giving rise to the disagreeable feeling
which one experiences when cutting a wise tooth. We should
always look into the mouth, as well as examine the gums beneath
the front teeth, or smell the breath, where we wish to assure our-

94 MBECDBT.

eelves as to the progress of the medicine. Another early symp-
tom is, a slight discoloration of the mucous membrane upon the
inside of the cheeks: it loses its fresh, red colour, and becomes
whitish, particularly opposite the crowns of the lower teeth, the
indentures of which soon manifest themselves upon it, and in a
short time, if the medicine be not lessened, ulceration will ensue
in that locality. One of the first places, however, where any
breach of surface occurs upon the mucous membrane is imme-.
diatcly below the red border of the under lip, opposite the junc-
tion of the gum with the lower incisors. About the same time
the tongue becomes slightly swollen, and its edge deeply indented
with the lower front teeth ; it is of a greyish-white colour, and
covered with slimy saliva. AH the glandular apparatus within
the mouth is then excited to excessive action ; the papillae of the
sublingual ducts become swollen and erect, and the ulcerations
upon the inside of the lower lip and opposite the buccal glands
upon the cheeks present the appearance of aphthous sores, greyish
in the centre, with a slight straw-coloured margin ; and saliva,
mixed with mucus, pours from every possible outlet. As, how-
ever, these observations are not intended as a dissertation on the
pharmaceutical preparations or therapeutic effects of mercury,
but are here put forward in order to explain its applicability to
certain diseases of the ear, it would be out of place to enter into
an exposition of the means best calculated to correct its illegiti*
mate action either upon the mouth or gastro-intcstinal membrane.

In the more chronic or subacute forms of aural disease — often
where the mucous membrane is extensively engaged, or when
congestion, more than inflammation, is present — mercury is a
valuable remedy, either as an alterative or to keep up sustained
but gentle action on the mouth ; and in such cases the milder
preparations, such as the hydrargyrum cum creta, in combination
with cicuta, will be found advantageous.

The third, and perhaps the most efficacious form, in which
mercury may be used, is that of the bichloride, still commonly
known in this country as the oxymuriate, one of the most va-
luable medicines of the entire Pharmacopoeia. A treatise might
be written on the virtues of this remedy, and the vast field of dis-

MBBCUBT. 95

ease over which it exercises a sanative influence. Combined with
Peruvian bark — which the chemists say is incompatible, but the
product of the decomposition said to be produced by which, may
be the very substance which acts most beneficially — it is almost a
panacea for most of the strumous inflammations in children and
young people ; and its power in controlling scrofulous ophthalmia,
comeitis, and iritis, &c., extends equally to the cure of kindred
affections in the ear. It is the best remedy I know of for inducing
absorption of lymphy deposits in the membrana tympani, and
general thickening and opacity of that structure, as well as very old
cases of chronic inflammation of the membrane of the cavitas
tympani. It is, moreover, when properly administered, one of the
safest as well as the surest preparations of mercury : it may be
taken for a great length of time ; it seldom interferes with the or-
dinary occupations or amusements of the individual; it leaves no
ill effects; it rarely induces ptyalism; and patients improve in
health, and absolutely grow fat while using it.* It may be given
alone, either in pill or dissolved in nitrous ether, proof spirits, or
some of the tinctures, such as cascarilla, but it is much more solu-
ble in distilled water than is generally known ; it may be com-
bined with the muriated tincture of iron with good effect, or with
some of the preparations ofsarsaparilla; but bark — either the tinc-
ture, syrup, or decoction — ^is of all others the medicine best suited
for its administration. Our Dublin preparation of the syrup is,
particularly for children, a good vehicle for it, provided the mi-
neral is first dissolved in a little distilled water. Oxy muriate of
mercury and bark sometimes disagree, producing, shortly after be-
ing taken, pain in the stomach, tenesmus, griping, and even diar-
rhoea; in such cases it will generally be found that it was taken
before breakfast or on an empty stomach ; it should therefore be
administered an hour or two after meals. But when it disagrees,
even with such precautions, a separation of the constituents will
obviate the unpleasant effects : thus the mercury may be taken an
hour or two before or after the bark. From the sixteenth to the
eighteenth, or even a quarter of a grain, may be taken three times

* I undentand that the bichloride of merctuy, in large doses, is used to fatten and
Impioye the condition of horses in the West Indies.

96 MBaCUBT.

a day, according to the circumstances of the case, for weeks and
even months together, with, however, short intervals occasionally.

Deafness has been attributed to the over-use and abuse of mer-
cury, and I was myself once under the impression that such
might happen, from having seen some cases of almost complete
loss of hearing in persons who, it was stated, had taken large quan-
tities of mercury for a long time. I have recently made particu*
lar inquiry after these cases, and I have carefully examined the
membrana tympani in each, and in every case I found it thick*
ened, opaque, and manifesting all the appearances consequent
upon deposits between its layers, — the result, no doubt, of spe*
cific inflammation. Each of these cases were originally syphilitic,
and exhibited evident traces of a scrofulous taint, and they all
acknowledged that they had taken the mercury most irregu-
larly, and had been for years affected with secondary symptoms.
I think it yet remains to be proved that mercury produces inflam-
mation of either the eyes or ears. Practitioners of the present day
have received, as by a sort of hereditary tradition, and still enter-
tain the idea that mercury will produce iritis ; and the homoeopaths
flourish the assertion whenever and wherever an opportunity
offers, as a proof of the grand principle of their doctrine. Is
it a fact that mercury taken for the cure of other diseases than
those which will of themselves induce inflammation of the iris,
the sclerotic, or choroid, — such as syphilis, rheumatism, gout, or
scrofula, — has ever caused the train of symptoms of internal in-
flammation of the eye generally known as iritis?

The preparations of iodine and potassium may be employed
in aural affections, and will be found efflcacious just as they act
on the general health or the diseases of other organs ; so likewise
with cod-liver oil. The only medicine I know of which appears
to exercise an influence upon tinnitus aurium is leopard's bane,
the arnica montana, formerly much in use for rheumatic affec-
tions, and as an external application in sprains and bruises. The
value of this and other remedies in diseases of the ear, as well as
their mode of administration or application, will be explained
when speaking of the diseases to which they are applicable.

97

CHAPTER III.

STATISTICS AKD HOSOLOOT OF BAR DISEASES.

StatisUcs of St Mark's Hospital — Analogy between Diseases of the Eye and Ear;
Amanrosb and Nervous Deafiiess. — The Author's Table of 2385 Cases : their Dis-
eases, Ages, and Sexes. — Kramer's Statistics, their Value and Peculiarities. — ^Tscbar-
ner's Statistics. — ^Toynbee's Pathological InvestigatioDS. — The Author's Abstract of
200 Cases. — Proofe of Inflammatory Action in Ear Diseases. — ^Nosological Arrange-
ments of Galen, Buchanan, Harvey, Deleau, Kramer, Pilcher, lincke, &c.~The
Anatomical and Pathological Bases. — The Author's Clasdfication.

THE subject of vital statistics has of late years engaged the at*
tention of the scientific world more than at any former pe-
riod, and within the last few years the statistics of ear diseases have
been noticed by a few Continental writers. As, however, some
time must elapse before an exact knowledge of aural diseases is
arrived at, and until their nomenclature is fixed, such variety
must exist in the accounts of different authors as to lead to ap-
parent discrepancy, if not to a semblance of ignorance. It is
not as in general medicine or surgery^ where there is but little
danger among educated practitioners of mistakes in registering
cases of fever, pneumonia, peritonitis, or calculus ; — in diseases of
the ear, what one practitioner would call nervous deafness, ano-
ther might believe to be the result of some organic lesion conse-
quent upon inflammation, &c. ; and so the proportion which the
different diseases bear to one another or the whole would vary
according to the mode of registering, and the amount of know-
ledge and peculiar opinions of the registrar. As therefore statis-
tics involve nomenclature, so does the latter subject lead us to the
consideration of nosological arrangement.

The earliest and most complete statistics of ear diseases pub-
lished in these Kingdoms were, I believe, those appended to
the Report of St. Mark's Hospital for the year 1844-45. Since
that period as accurate a registry has been kept of all the
cases which presented as the means and appliances at any public

u

98 STATISTICS OP BAB DISBASBS.

institution can afford, and the results thereof have appeared from
time to time either in the Annual Reports or in the public journals.
I do not think it possible to keep a sufficiently accurate account
of all private patients, and therefore none such are included in
these returns. From the 1st of March, 1844, to the Ist October,
1852, as shown by the accompanying Table at page 102, the num*
ber of ear patients whose diseases were registered amounted to
2385 ; — besides very many others of whose disease no note was
taken at the time.

When I first commenced the study of aural diseases, I be-
lieved that in most cases where I had no positive evidence of
disease in the meatus or membrana tympani, the deafness and
tinnitus were caused by some defect in the nerve of hearing, or
what is termed *' nervous deainess.** As, however, my field of ob-
servation extended, and as my knowledge of the healthy and mor-
bid appearances of the membrane improved, I gradually began to
find that the instances of deafness with perfectly healthy Qrmpanal
membranes which fell under my observation were comparatively
few : while I daily became familiarized with a variety of patholo-
gical appearances in these structures, which I was soon convinced
were the result of different forms of inflammation of an acute or
chronic nature, arising from some idiopathic or specific cause.
These appearances naturally led me to pay particular attention to
those diseases in their early stages, — the only period at which,
in most of them, art can be of any avail

As the acquisition of knowledge is progressive, so my means
of forming an accurate diagnosis improved with my experience,
and therefore the value to be sttached to the early years included
in this Table is not so great as that for a later period. I have con-
sequently divided the results into two portions: the first includ-
ing three, the second four and a half, years. In the first portion
of the Table, out of 706 recorded cases, 85 were set down to
^ nervous deafness,** which I am inclined to think was an exag-
geration, as by a more carefully conducted examination, and with
increased experience, I found but 18 cases out of 1679 in the second
period ; having observed since the former period that many of the
cases attributed, for want of abetter name, to " nervous deafness,**

STATISTICS OF BAB DI8BA8BS. 99

showed such manifest appearances of diseased action in the mem-
brana tympani, that little doubt now remains upon my mind that
the defect of hearing was to be attributed not to paralysis or want
of power in the auditory nenres, but to lesions produced by in-
flammation. Again, in the first period there is no entry for
thickening and opacity of the membrana tympani, the unmistake-
able result of inflammation, but as many as 219 in the second;
and under the head of inflammation of a chronic character, we
find but 82 cases noted in the first, and 314 in the second period.

Out of the 2385 cases recorded we perceive that 579 were
simply cases of impaired hearing produced by impaction of the
external auditory passage with cerumen; 114 of so-called nervous
deafness; 25 of tinnitus aurium, unaccompanied at the time by
deafness or any apparent disease ; 14 of otalgia ; 7 of deaf-dumb-
ness, either congenital or acquired ; 2 of accidental haemorrhage
from the tympanal cavity ; 7 of congenital malformation ; 20 of
coUiqpsed membrana tympani ; and 2 of tumours of the auricle: —
making in all but 770 diseases of the ear not directly traceable to
inflammation or its effects.

Let us reason by analogy on this great preponderance of in-
flammatory affections among diseases of the ear from what may
be observed of the organs of sight. Out of 11,233 eye cases regis-
tered at'St. Mark's Hospital, but 857 were diseases of the retina
and optic nerve, and only 341 of these were instances of un-
complicated amaurosis, or about 1 in every 33 of the entire.*
Whereas in the registry of ear diseases hereunto appended, the
proporUon of nervous deafness, including the exaggerated entry
in the first period already alluded to, is about 1 in 21 ; but by i^
more accurate registry it is probable that it would bear a some-
what less proportion to the whole than amaurosis does to the ge-
neral mass of diseases of the eye. In former times cases of loss of
vision by what was called gutta screna, and also glaucoma, were
said to be very frequent. Some time later, owing to the improved
condition of ophthalmic pathology and diagnosis, observers re-
duced both these affections to a smaller compass under the name

* See Report oa the Namber and Condition of the Blind ia Ireland in Mufh, 1S51,
in the Report of the Ceneoi Commiaaionen for that period, Pait n. page 45.

h2

100 STATISTICS OF BAB DI8BABB8.

of amaurosis. Still more recently, and as practitioners became
better acquainted with the various forms of congestion and other
diseases of the choroid, and the different silent inflammations
which may be set up in the eye, the latter disease was still further
reduced; and now I think it will be acknowledged by those who
have enjoyed extensive opportunities for studying ophthalmic
affections, that ti'ue uncomplicated amaurosis, not resulting from
disease of the brain or its membranes, or tumours within the cra-
nium or the orbit, but proceeding &om simple paralysis of the
optic nerve or retina, are comparatively rare. When such cases
are pronounced incurable at a public institution or in private
practice, and are either told so honestly, or sent to the country to
be got rid of, or to improve their health, broken down by disease
or treatment, they are generally lost sight of; but if we examine
the inmates of a blind asylum we are at once struck with the fact
that nine-tenths of the cases of loss of vision there presented are
the result of inflammatory action ; the cases of pure unmixed
amaurosis are comparatively rare, either on account of their actual
scarcity, or because the patients so affected have already been
carried off by the cerebral disease, which was the original cause
of their blindness.

From an analysis of the following Table we perceive that dis-
eases of the auricle and external meatus amount to nearly one-
half of the entire ; affections of the mcmbrana tympani, exclusive
of collapse, number 819, or nearly one-third of the entire ; and
diseases of the middle ear amount to 101, or about a twenty-third
of the whole. The term otiUa is here applied solely to inflamma-
tions of the cavity of the tympanum ; but as it is not possible to
limit inflammatory action to the peculiar structure in which it is
originally set up, we may suppose that a large proportion of the
diseases registered as affections of the external drum-head must
have extended sooner or later to the internal surface of that mem-
brane, and the investitures of the cavity of which it forms the
outer boundary.

The subject of otorrhoea is difficult to manage, either in a sta-
tistical or a nosological point of view, owing to the variety of
causes which may give rise to that affection, the different portions

STATISTICS OF BAR DISEASES, 101

of the ear from which it may proceed, its various complications,
and the several structures which may be originally or subse-
quently engaged. The principal division made of that disease
in the Statistical Table is into external, when the raembrana
tympani remains intact: and internal, from the circumstance of
its perforation or total destruction, thereby allowing the mucous
membrane of the middle ear to be exposed to the action of the
atmosphere. The eleven cases of deaf-dumbness must not be
taken as indicative of the real proportion which that affection
bears to the other diseases of the ear ; in this country the number
of cases of congenital deafness applying at a public institution are
always accidental. The statistics of that class are set forth in
Chapter vii. Of the entire cases recorded, the sexes are in the
proportion of 100 males to 79 females, these proportions, however,
vary according to the different diseases : thus in eczematous and
kindred affections of the auricle and meatus the females predo-
minated, whereas among the cases of deafness arising from col-
lections of cerumen, the male sex formed the majority. In cases
attributed to nervous deafness the females predominated ; whereas
both in otorrhcea and all tlie inflammatory affections, the sexes
were nearly equal ; but cases of otorrhcea attended with polypus
were much more frequent in the male than in the female.
With respect to the relative frequency of aural diseases at par-
ticular periods of life, the following Table affords accurate infor-
mation, as the ages of the different patients were carefully regis*
tered, — not the ages at which the disease appeared, but that at
which the patients applied to the Institution. This Table, it must
be remembered, does not include all the diseases enumerated in
the Nosology, or specified in this work, as, for the purposes in-
tended at a public institution too minute a subdivision would be
disadvantageous, even were it possible, to continue it for a num-
ber of years. It is unnecessary here to enter further into its
minutiae, to discuss its results, or enlarge upon the deductions
which might be drawn from it; like all such Tables it must be
more or less defective ; but so long as statistical calculations are
admitted in medicine, it is, like others of the same class, entitled
to its value.

Tabu jAomw^ Ot difenmi Dmam cfOts Ear, rtffiMered a

Under SJ 6 te lit.

CoogeoiUl UaUbnaalioo otExtenul j

Eat,

AbnaiarMMildGUBd, . . . .
DbMM of HHtoid Pmctn, . . . .
Ecuau and Herp™ "f Auriek, . .
Tnmoon is ditto,

loinMtioD ol Exienal llMttt^ .
KUo, with AcoU OtonlKB^ . . .

Ditto, „ Cbnnid „

Otdfrhaa, wUh Polypoid Gnwthi, .
AbK«M In EzWnua Meatu*, . . .
CoDtnetioo uul UleeratioD In dilto, .
Vea^ Bodiet in ditto,

imaicms Colkctiolu in ditto, . .

iiimwIlMi cdCciabnuu lympani,

DHto, SobMole (StnuDooi), . . ,

Ditto, Sfphililic

Ditto, Ghnoie,

Abcnu in Herobniui TjfDpanl, . ,
Uicoration and Pcifontlon of lUUo,

ThlckiniagtiHlOpkoityofMoiiibnui* \
TfiapMi, I

GruiiiUr utd TumUr ditto, . . .

ColUpM of Mcmbrui* Tympuii, . .

iDflunimtion oT Carllu l^iapml ',
(OUlii), I

Ditto, with Cwiei,

Hamorrbag* frciai Tyinpuinm, . ,

OtilgU,

Xertans Dtafbou,

PoK-Fcbrlle Dofnew,

l>elf-DalnbnCB,

DufDen titm Diieu* of Throai, .

SSSe 77 M l« 118 148 U8

SL Mart't Soapitid,/rom Itt MareJk, 1844. to Ut October, 1853.

8Ho40.[|*l lo50. Upwtni,.

1811 1847

less.

AbKKu ot Maetoid GUnd.
Diwase of MoMoid Proc«M.
Ecuma and Herpes oT Auricle.
TnmoDn! in ditto.

Ditto, with AcQte OtoirlKea.
Ditks „ Chroaio „
OtOTTbow, with Pdiy^A Orowthg,
Abaceu in ExtDrnol Meatus.
ConlractioQ and Ulceratton Id ditto.
VotAga Bodies in ditto.
CeramaiiODS CoDectiotu in ditto.

Ditto, Subacute (Slniroom).
Ditto, SiTiMlitic.
ratto, Chronic

Abwoa in Hembnni TjiapKi.
: Ulceration and Perfontioa of ditto,
with Otorrhea.

J Thickening andOpadtj-orMembnuia
T)'m[)»Qi.
Granalar and Taacnlai ditto.
CoUapH of Hembrana Tympanl.
Influnmation of Caritaa Tapani

(Otitii).
Ditto, Willi Cariea.
Hnmorrtiagg from Tympanom.
T^nnilaa Aorium.
Otalgia.

Ncrroui Deafnesj.
Post-Pebrilo Deafneu.
Deaf-Dumbneai.
Deafhoa from Diiaan of Throat.

104 ^* ' KBAKBm's STATISTICS.

In 1845 Dr. Kramer published his BdtrSge zur Ohrenheilkundej
in which he has given an extensive statistical chart and nineteen
tables connected with diseases of the ear. The number of cases
therein recorded amounted to 2000, of which but 5 were diseases
of the auricle, and 281, or one-seventh, of the whole, were dis-
eases of the external auditory passage, including under the head
of inflammation of the skin 213 cases of impactions with wax;
a position which yet remains to be proved. He includes all the
diseases of the tympanal membrane with those of the external ear,
whereas, in my opinion, they belong equally, if not more so, to
those of the middle ear : indeed, I believe that the chronic as well
as the acute inflammation of the membrane is accompanied by dis-
ease in the middle ear more frequently than disease in the audi-
tory passage. Of the 2000 cases observed, the inflammations of the
tympanal membrane amounted to 442, or something less than one
fourth of the whole; and of these cases, 45 were acute, and 397
chronic inflammations. 164, or about one-twelfth of the whole,
were inflammations of the middle car, but which he does not tell
us were originally connected with, or subsequently produced
changes in, the mcmbrana tympani. If in these 164 cases the
inflammation of the mucous membrane of the middle ear was con-
fined to that lining the bony parietes of this cavity, — not extend-
ing over the extensive surface stretched upon the back of the
membrana tympani, not propagating inflammatory action there,
and producing the effects of inflammation upon transparent or dia-
phanous membranes, — as we sec it does upon the aqueous mem-
brane lining the back of the cornea, — then have we no analogy for
such a state of things in any of the other departments of patho-
logy. To these 164 cases of inflammation of the lining of the tym-
panum, he has added 30 of alterations in the Eustachian tube, — 28
of stricture, and 2 of occlusion, —but for which he had no other
warrant than that he was unable to pass air or solid instruments
through the tube. There were 4 cases of inflammation of the pe-
riosteum of the cavity — in all, 198 diseases of the middle ear, or
one-tenth of the whole. Among the diseases of the ear he has
included 46 instances of deaf-dumbness. With most of these sta-
tistics we find no fault; and to the various tables exhibiting the

kbambb's statistics. 105

causes, ages, sexes, &c., we must, in common with all who will
examine them, award to the zeal and industry of their author the
amount of credit which they deserve. Some of these tables are,
however, more curious than valuable ; thus No. viii. shows the
fatherland or country of his different patients from all parts of
Europe and from America I

When we come to examine into the chief cause of deafness
enumerated by the Berlin aurist, we at once perceive that his fa-
vourite theory of " nervous deafness*' has been pressed into the
service, and this item made to exhibit a magnitude which we
have strong hopes of seeing Dr. Kramer himself one day criticise
with more severity than we are now willing to do for him. Of
the entire number of cases recorded, 1028, or somewhat more
than one-half of the whole, are set down as ^^Nervose Taubheii.'"
The most that can be said of these 1028 cases, many of which
may, I doubt not, have been caused by affections of the auditory
nerve, is, that in these, the parts capable of inspection exhibited
to his eye no symptoms of disease. In which case, he says, ** the
use of the ear catheter is the only means, either by blowing through
it, or by injecting compressed air from the air-press, or by the in*
troduction of a catgut string, or a small whalebone, or ivory probe,
to learn the condition of the Eustachian tube and the cavity of
the tympanum, and thereby, in the cases in question, tojiidge of
the condition of the auditory nerve^'! But even this hazardous
mode of making an examination, — by introducing a foreign sub-
stance into the cavity of the tympanum ! — is at best but a negative
proof. By it the condition of the ossicula, the membrane of the
fenestra rotunda, the fine mucous membrane, with its nerves, lin-
ing the tympanic cavity, the state of the labyrinth and the inter-
nal ear, or the brain, cannot he investigated* Is there any other
organ of sense in which the affection of the nerve bears the same
proportion to all the other diseases of the part as this? Would
any table of the affections of the eye be acknowledged as authen-
tic in which more than one-half of the diseases of that organ were
ascribed to amaurosis, or amaurosis not consequent upon some in-

* A very admirable analysis of Kramer's Statistics appeared in the British and Fo-
reign Msdieal Benew for July, 1S47.

106 KRAMSB's VBBTOUB DBAniBSS.

flammatory condition ? Let us ask what Dr. Kramer means by
nervous deafness ? He himself answers, in the first edition of his
JSrkenntniu und Heilung der OhrenkrankheUen, that such cases are
those in which ** we find the hearing altered and debilitated with-
out any organic abnormal state in any part of the whole organ of
hearing" (see Bennett's translation, page 255). And in the para*
graph following he adds, with great justice, ''This nervous deaf-
ness has hitherto been frequently misused as a cloak for ignorance
and want of skill in any doubtful or obscure disease of the ear.**
Now, all the value we derive from the foregoing definition is, as
already stated, that the examination of such cases afforded nega>
tive evidence as to the existence of disease at the moment in those
parts visible to the eye, or the condition of which was apprecia-
able by the ear by means of the air-douche, &c. Sixteen years
ago the author divided this nervous deafness into that attended
with tinnitus, or the erethitic, which he believed to be amenable
to treatment, and the torpid, in which there was a total absence of
tinnitus throughout the whole course of the disease. Let us read
from Dr. Bennett's faithful translation of the work just alluded to
what was Dr. Kramer's exposition of the physical signs of nervous
deafness in the year 1836. All traces of cerumenous secretion va-
nish by degrees ; the Eustachian tube, as also the middle ear, is in
general firee and open, and a stream of air passes readily up to the
tjrmpanal membrane ; and then he says, '* In both forms of nervous
deafness" (i.e. the torpid and erethitic) "I have almost always/mmd
the membrana tympani white like paper ^ and opaque ; probably in
consequence of the action of its absorbent vessels having been im-
paired.** Now, had Dr. Kramer been conversant with the normal,
healthy condition of the membrana tympani, he would have known
that it was shining, diaphanous, or semi-transparent, and of a yel-
low-grey tint (except toward its superior attachment, and along the
line of insertion of the handle of the hammer bone), somewhat
the colour of gold-beater's skin, or, what bears a still closer simi-
litude on account of its greater thickness and fleshy tint, the thin
sheet gutta percha which has been lately introduced for surgical
purposes.

To state, then, that a texture, the normal condition of which is

KBAMBR^fl NERVOUS DBAPNB8S. 107

known to every observer of it in the living healthy state,* to be
what I have described, is '* white like paper, and opaque,** ex-
hibits either defective powers of observation, insufficient means
for investigation, or a want of knowledge of the natural condition
of the parts. What would be thought of an ophthalmic surgeon
who, in describing a case of amaurosis, stated that all the structures
were normal, but that, at the same time, the cornea was opaque,
or even cloudy ? Tes, I do believe that in the cases observed by
Kramer, and described in his original work, the membrana tym*
pani was opaque, like white paper, because it had been previously
subjected to inflammatory action, and the opaque deposit was
the well-known consequence thereof As to his mode of account-
ing for the opacity by a want of action in the absorbent vessels,
I do not think it requires refutation. Some of the worst cases of
defective hearing, apparently induced by paralysis or impaired
function of the auditory nerves, and which are of many years'
standing, have perfectly normal tympanal membranes. Further-
more, if those cases attributed to nervous deafness showed such
manifest disease in the external membrane of the tympanum,
which VH18 seen, how much greater may not have been the morbid
changes in the parts beyond it, both in the middle and internal
ear, which were not seen ?

In the Statistics already alluded to. Dr. Kramer modified his
former views as regards the division of nervous deafness, and
classified both under the general head of diseases of the inner ear
— as nervdse Taubheit. Again, in 1849, in the second edition of
his principal work on Diseases of the Ear, he defines the affec-
tions in the chapter devoted to the consideration of nervous dis-
eases of the inner ear as, hard-hearingness, and deafness; and
without any preliminary observations, at once enters into the
details of cases and observations in proof of the so-called nervous

* AnAtomists seldom see the membrana tympani except in the dead state, when
partial decmnpoaition has set in, and its external cnticalar layer has become thickened
sod opaque : therefore it is that their descriptions of this stractore are not as accurate as
9i other parts of the human body. Suppose anatomists were to describe the cornea only
from the condition it presents in subjects five or six days dead, how little would have
baen writtea about the polish, traaq>arency, and curatnre of that beautiful stmctors!

108 KBAMBB*8 STATISTICS.

deafness. And in almost all the cases recorded in that section
(p. 668, from No. 128 to No. 165) we read of the membrana tym-
pani being clear, shining, and transparent, thus differing from his
observations made in 1836, when the same structure was almost
always white like paper, and opaque.

Mr. Toynbee's observations and dissections, having a direct
influence on the statement set forth in these statistics, naturally
attracted much attention, and would, unless disproved by counter
facts, be a " heavy blow and a great discouragement** to Dr.
Kramer*8 views, and, consequently, in the Medical Times and
Gazette (for October 16th, 1852), the Prussian surgeon is again
in print on the subject, — fearful that his English professional
brethren should not fully appreciate the results of his " exten-
sive aural practice of upwards of twenty-two years.** He begs
his readers to be satisfied with his pathological ( ?) sketch of real,
not fancied diseases, in contradistinction to the researches of Mr.
Toynbee. Appended to that paper is a table, republished from
page 113 of his OhrenheiUcundie in den Jahren 1849 und 1850,
giving the result of 4000 cases, — 2000 additional to the statistics
published in 1845, — ^and there again nervous diseases of the ear
are made to exhibit the same proportion to the entire which they
did in the previous calculations, for we find 1875 cases of nervous
deafness out of the additional 2000 set down under the respective
heads of " hardness of hearing,** and ** deafness.** Time and pa-
thological research will eventually determine the matter in dis-
pute, but at present it will be for the practical surgeon to judge
between Mr. Toynbee*s dissections, which he still possesses, and
which can be examined by any person who pleases to wait upon
him, — but the inferences from which Kramer says " are of a purely
theoretical character,** inducing '' false consequences and conclu-
sions,**— and the figures given as the result of the latter s private
practice, and set forth so ostentatiously in his various publications.

Let the profession also compare the result of the observations
and brief details o( facts set forth in the tabulated abstract of 200
cases faithfully taken as they presented at a public hospital, in the
presence of, and equally observed by, a number of medical men and
intelligent students, many of whom will no doubt recognise these

TSCHABNBB*8 STATISTICS. 109

cases when they read them, given at the conclusion of this chapter,
with the figures afforded from time to time by Dr. Kramer.
Far be it from me to deny the great prevalence of what is termed
nervous deafness ; in the foregoing observations I merely doubt
the proportion which, according to the German aurist's belief,
they bear to the entire mass of diseases of the organ of hearing.
It is easy to give names to diseases and to attach numbers thereto,
it is another matter faithfully to record the appearances which
each case presented during life or exhibited after death. When
Dr. Kramer has demonstrated to a public class of students and
practitioners capable of observing for themselves— the only true
method of clinical investigation — the healthy character of the
membrana tympani in one-half of the next 2000 cases which he
publishes, I think his figures may, but not until then, be placed
in comparison with the facts described by British observers. Sta-
tistical tables and calculations are really valuable only when we
can rely upon the original investigations from which they were
deduced ; if the materials have been loosely collected, or for any
special purpose, or to support any preconceived theory, such cir*
cumstances naturally influence the value to be set upon all sub-
sequent arrangements, no matter how ingenious. Statistical cal-
culations remind one of the kaleidoscope, which, when turned or
shaken, presents new and beautiful combinations of figure and
colour, irrespective of the objects which produced such being
crooked pins and glass beads or spangles and diamonds.

Dr. Tschamer of Berne published in 1849 the result of 200
cases in a small tract, Beitrag zur StatiUik der Ohrenkrankheiten,
the sexes being in the proportion of 115 men to 85 women.
Among these, both ears were affected in 158 cases ; the right in
22, and the left in 20. The diseases recorded affected the diffe-
rent portions of the organ of hearing in the following proportions:
— The auricle, 10; external meatus and auditory canal, 163; the
membrana tympani, 122 ; the cavitas tjrmpani, 70 ; the Eusta-
chian tube, 74; and the labyrinth, 72: but the diseases affecting
several of these parts co-existed. The proportion of diseases of
the labyrinth which the author has recorded, and which we are
led to suppose he diagnosed, would, if true, be curious. It is un-

110 T0TVBBS*8 DUSICTJOVS.

neceaBary to follow the author through his yarious and ingenious
tables further. Mr. Tearsley and Dr. Schmalz have likewise
written upon, and published tables of the statistics of^ ear diseases.

As already stated at page 37, Mr. Tojnbee has dissected the
ears of 750 persons furnished to him from different sources ; and of
these he has published the result of the examination of 915 ears.*
Of these, 303 were in a healthy state ; and on this small proportion
of only one*third found in a normal condition the author remarks,
" To those, however, who have given the subject much considera-
tion, and who are aware of the wide-spread prevalence of deafness
in its varying degrees among all classes of society, the dissections
will not, perhaps, be thought to exhibit any unusual proportion
of diseased to healthy specimens."* Of the remaining 612 ears,
184 had belonged to persons who were known during life to have
been deaf, and these are the really valuable cases, though it would
have much increased their value had the amount of deafness and
other symptoms during life been recorded ; 70 showed upon dis-
section such manifest traces of disease as left little doubt that the
persons must have had in life defective hearing ; and 358 were
believed by the author to be in a state of incipient deafness. The
following summary gives the result of these investigations ; but
so many ears exhibited morbid appearances in different parts, that
the totals of the different sections are not to be considered as mak-
ing up the entire 612 ears.

The external meatus showed disease in 80 instances, or 1 in
10^: consisting of,— collections of cerumen and epithelium, 58;
of pus and epithelium, 13; contraction of canal with alterations
in its lining membrane and osseous parietes, 9.

The membrana tympani was diseased in 209 instances, or
nearly 1 in every 3 ; of these there were, with the membrane
white, thickened, or vascular, 52; concave externally or flat, 15;
concave, and adhering to promontory, 21 ; concave, with deposits
of calcareous matter, 4; perforated, or altogether destroyed, 51 ;
and adherent to, or connected by bands with, the ossicula or pro-
montory, 66.

* Sm the ICfldioo-Chirargical TnnsactioiiA, vols. xxi?. 1S41, zxtL 1848, xxxiL
1849,— this Utt containi Ublet for the entire.

totnbbb'8 disssctioks. Ill

The cavitas tjmpani presented evidences of disease in the
following proportions : it contained morbid collections in 107 ex-
aminations, or about 1 in every 6, to speak in round numbers;
consisting of, — collections of mucus, with the lining membrane
healthy, 43; and with the membrane thickened, 5; filled with
portions of cerumen and epithelial scales, the result of destruction
or perforation of the membrana tympani, 2 ; containing pus, with
the membrane thickened, 15 ; filled with blood, 4; with serum or
lymph, 10; scrofulous matter, 20 ; oily matter, 1 ; and calcareous
matter, 7.

The mucous membrane of the cavitas tympani was diseased
in 310 cases, or more than one-half of those examined. In 66 in-
stances it was more vascular than natural; in 179 it was thick-
ened; in 22 so thick as to bury the whole of the stapes; in 8 so
thick as to fill the tympanum ; and in 5 it was pulpy. The re-
maining examinations showed the membrane ulcerated and thick,
20; with black pigment secreted beneath it, 2 ; with blood effused
under it, 8 ; and with serum in the same position, 1. It is pro-
bable, however, that some of these latter appearances may have
been post-mortem products, and that many of the characters de«
tailed in this section generally may have resulted from the dis-
eases which were the immediate causes of death in the patients,
and not from any previous affections in the organs of hearing.

Bands of adhesion were found to exist in the cavity of the
tympanum in 179 cases, or 1 in 3*42 of the whole. These bands
passed between the stapes and promontory in 130 instances; were
connected with the incus, stapes, and promontory in 8 ; joined the
malleus with surrounding parts in 12 ; connected all the ossicles
in 13; the ossicles with the promontory in 9 ; the tensor tympani
muscle and the stapes in 3 ; and the chorda tympani nerve, with
the adjacent parts, in 4.

The state of the ossicula is thus described: the malleus adhe-
rent to the promontory, 1 ; removed by absorption, ulceration, or
caries, 6 ; and found with incus in mastoid cells, 1 ; the incus was
in whole or in part removed in 10 cases ; disconnected from stapes
and malleus in 3 ; the stapes was found either partially or com-
pletely ancbylosed, or more firmly attached than natural with the

112 TOTVBBB*8 RB8B ARCHES.

fenestra ovalis, in 30 instances ; disconnected or in a state of ab-
sorption, 4 ; and projecting into vestibule, 1 ; all the ossicles were
either removed, carious, or disconnected, in 5 ears. Thus the
number of cases in which the ossicles were diseased or displaced
amounted to 61, or one-tenth of the whole, a proportion which
will not appear exaggerated to persons conversant with the de-
structive results which follow otorrhoea with exposure of the
tympanal cavity.

The osseous walls of the tympanum were : thickened, 1 ; car
rious, 2 ; partially deficient superiorly, 54 ; and inferiorly, 22.
The carotid canal was contracted 3 tiroes, making in all 82 cases
of disease of the bony parietes, or 1 in every 7-46.

The membrane of the fenestra rotunda was diseased 5 times ;
the tensor tympani muscle atrophied, 7 ; and attached to stapes
once.

The Eustachian tube showed symptoms of disease in 21 of the
examinations, or 1 in 29 ; contained mucus, 10 ; its lining mem-
brane thickened, vascular, or congested, 8 ; and with bands con-
necting its parietes, 3. It must, however, be remarked that it
was only the upper portion of the tube which was submitted to
examination.

The internal ear exhibited the following peculiarities : the
membranous labyrinth thickened, 4 ; atrophied, 6 ; the labyrin-
thine fluids deficient, 8; the vestibule and cochlea containing
bloody serum, 1 ; pus, 1 ; a band crossing the vestibule, 1.

Considerable difficulty must always be experienced in dis-
^ctingf^or in discovering pathological changes in the internal ear,
particularly in measuring any deficiency of its natural fluids. We
find all the dissections of the internal ear in the column for the
184 persons previously known to be deaf. The following ob-
servations upon these dissections are so faithful, and so much
in accordance with my own ideas upon the subject, that I in-
sert them. ** The'^fact of a thickened or otherwise deranged
state of the mucous membrane lining the tympanic cavity being
one of the most common pathological conditions of the organ of
hearing, is theH^roadest general result of the dissections; and as
cases carefully examined, noted, and studied as they have arisen

THB REGISTBT OF OASES. 113

in practice, lead to the same conclusion, I have little hesitation
in stating disease of that membrane to be the most usual cause of
deafness. What are the history and symptoms of the great ma-
jority of cases of deafness unattended by discharge? Cold has
been caught, uneasiness has been felt, renewed attacks of cold have
added to the severity of the symptoms ; advice is at length sought,
and examination shows the external meatus deprived of cerumeni
and frequently deficient in natural sensibility, while, towards the
membrana tympani, its appearance is red and smooth ; the mem-
brana tympani is entire, its surface shines, but it is hazy, opaque,
or as white as parchment, and, consequently, the handle of the
malleus may be discerned with varying degrees of distinctness, or
cease to be visible at all. Upon a forcible expiration with closed
nostrils, the air, by means of the otoscope,* can almost always be
heard to enter the tympanum, not gradually, however, as when
the organ is healthy, but with a puffing, bubbling, or cracking
sound, as though impeded in its progress.'*

I have at page 52 described the method of taking cases at St
Marks Hospital. The history, progress, and treatment of the
first twenty-four cases in the following Registry have been already
detailed at length in the Medical Times and Gazette, for 1851
and 1852, a reference to which will show the manner in which they
were reported ; and portions of them are inserted in the body of
this work. The remainder are susceptible of publication like the
former, did space permit. From the voluminous notes of these, the
following abstract of 200 instances which presented, in succes-
sion, during the early part of the year 1850, has been drawn up.
Many other cases occurred of simple impaction of the external
auditory canal with cerumen, which have not been included in the
following abstract, except where, upon the removal of the me-
chanical impediment, the lining of the canal, or the external sur-
face of the membrana tympani, appeared diseased from other
causes, or in consequence of the long-continued presence of the
offending body.

^ Otoscope — an eUstic stethoacope, eighteen inches long, the ends tipped with ivory ;
one extremity of which is inserted into the meatus of the patient, and the other applied
to that of the examiner.

I

BB0I8THT OF ElB CASES.

Kd.

'C

E.r

DantlOD

or

o(

H«rinf

SUIBOfAnrieta.

StMe gf Enmul Mirtu ud CUal.

t™.

I«l.

DllUDIX.

R.

Ufon.

Biocbo.

Konn.1.

Dry, white, and poliihed ; l»d ili»-

1

H.

30

chstK* rormerlf .

L.

DltU).

6!ndK*.

Ditto.

Ditto

i

F.

is

E.

4y«a.

GlDcbei.

NorautL

a

U.

19

E.

Touching.

Normal; poat-

Normal

■uralglind in

iBtUe oTiup-
purniion.
Komd.

r

L.

1 moDth.

Touching.

Dry. polished, grey; no ceromeu. . .

i

H.

!0J

1

IL

Dilto-

None.

Ditto.

Pale ; more polufaed than left. . . .

i

H.

IS

L,

....

4 inches.

NormJ.

niciii on it. removal, cuticle thick-

R.

Gmuillu.

None.

KomaL

6

U.

to

naturaL

L.
I-

Ditto.
lyew.

On preuiire.
Touchiug.

IHlto.
KornuO.

Diiw

7

F.

14

through which a reddixli polypus ap-

peals, graving frum fuodua of canaL

R.

Ditto.

Sincbn.

Ditto.

D«le.J with diachargci) nicnibruii
thickened.

r

B.

4yun.

6 Inches.

NnrmBl.

Filled with discharg. ; tnembnoe

8

P.

so J

pinkish.

I

L.

DHlo.

On pmssurt

Ditto.

Dry ind scnly

fi

F.

80

It.

Twra.

.■i inche*

Normal

Nomal

10

M.

L.
L.

2 mmlliiL

1! inch™.
None,

llilto.
Norrad.

Ditto

Dry ; no cemmen

R.

Ditto.

3 inches.

Swollen.

Filled bv an abMeei of Intcgmneat. .

F.

B.

Yrat*.

....

NomuL

Itcmaykably Mnall.

f

R.

Yun.

3 inck«.

Normal.

NomiaL

ta

H.

16 J

l

L

ToMhing.

Ditto,

Ditto.

M.

11 t

L.

il'dBvi!

B inchai.

Kormal.

Tilled with whilLh diachargo. . . .

"{

R.

UUto,

4i>>rlH.

Ditto.

Filled with cerumen.

1-1

M.

L.

eweekiL

aiudiet

NurmaL

Filled with hrown, bard cenuoen,
thickened and detached.

16

F.

B.

10y«i«.

None on ei-
ther udo.

NonnaL

Stnall dry, pinkish ; no cenimen. . ,

w

M.

I.

U d.j-,.

None.

Moimal.

di>.charge. and flake* of detached

cuticle I men-brane florid red.

17

P.

L.

iyww.

3iDcbe&

HonnaL

Filled with muco-pamlent ditcharge,

piidt

18

H.

L.

3 month*.

NoranU

laioing gUiry

Nonnal

fluid tn belix.

BSaiBTRT OF EAB CA8B8.

115

t Mambrtna Timpani.

id and white ; rough and

; thickened ; malleus not

thable.

led than on right ; a crea-

adty occupies lower edge.

vyed

hickened, and opaque.

tl pinkish hue ; crescentic
aferiorly ; polished,
collapsed ; malleus pro-

with red patches. . . .

and opaque ; collapsed. .

opaque, and reddish. .
ng polypus, membrana
found to be opaque and

Middle Ear
and Eusta-
chian Tube.

hickened.

destroyed.

; opaque ; studded with
Ite specks ; collapsed.
ired ; thickened by inter-
posit ; unpolished; very
3eteriorly.

laque.

ring inferiorly ; dense
it in middle.

spotted by grey patches,
white, thicken^, opaque;
;e vascular.

rose-leaf colour. . . .
f layer of yellow lymph.

Uninflatable.

Ditto.

Membrane ex-
posed; deep-
red, smooth.

Pahi.

InflaUble.

Uninflatable.

Inflatable.

Uninflatable.

Ditto.
Inflatable.

Liiiingthicken-
ed, red, pulpy.
Uninflatable.

Inflatable.

Ditto.
Uninflatable.

Inflatable.
Uninflatable.

Ditto.

None.

Ditto.

None.

Dull throb- .
bing in
tumour.

Singing.
Ditto.

Noise.

None.

Buzzing.

State of
Throat.

Normal

Disease attrl-
bntodto

Cold and
posure.

Severe, lan-
cinating ;
varies.

None at pre
sent.

Great

Severe.

Ditto.

None.

Slight and

occasional.

* Siigiit.'

None.
TidaL

Singing and
rustling^

Singing.

Hissing.

None.

Ditto.

Hammering.

Falling of

water.
Ix>ud reports
Sawing.
None.

Singing.

Normal.

Tonsils en-
lai^ged.

Ulcerated.

• • • •

Normal.
NormaL

...

Normal.

Normal.

Membrane
red, swollen.

...

Normal.
Uvula elon-
gated.

• • • •

Normal.

Scarlatina.

Scrofola.

Syphilis.

Falling into
the sea.
....

Cold and
draught.

Scarlatina.

Cold.

Cold.

• • •

whitish, succulent, and

thickened, white; slightly
; malleus projecting.
pots of yellow lymph ef-
■urikoe.

ill aperture in upper and
part ; air passes with
noise.

Inflatable.

Slightly infla-
table.

Inflatable.

Normal.

None.
Severe.

None.

Boiling and
loud re-
ports.

Loud and in
cessant.

Buzzing and
throbbing.

None.

Auricle hot,
and slightly
painful. I

NormaL

NormaL
Normal

NormaL

NormaL

Nervousness

Scarlatina.

BIOISTST OF SAK C18B8.

No.

•b.

Ije

■s-

DonllDB

dST""'

tttmalAoM,.

■Utt or KlWHl MMBi Md CMd.

1ft

so

F.

p.

19
S4

B.
L.

Ijttt.

NomwL
Tcmching.

FibrmulunWDr
ID nnlK of
euh lol».
TbickcDcd.

Somul.

EliHimifd «lit; tdgti nll^iwid: oml
while. iluckuHd, ui<l rontaiits auAj
fluid.

Ciuwd bv condylonula Touml mugia ;
fetid BUiioiu discharge.

D«n««l one-third; GUod with bnEOj

tl
11

7.

p.

2S
BO

L.

n.

Bmanllu.

Toaching.
T«chine.

MoimiL

Si.oneii,minh«-

p*n. firn-red,

M

p.

»

B.

Cj-MFi.

SoM.

oiu nuJiiion.
tliml.lbk-k.z'nKl,
cnbrgrd, ll.
fiflHe oblilcre-
Ud; ■ diuJty
Lrown.
NorauiL

A nsrroir ■li^ filled with cnuU; Uniw
ukotted.

11

F.

(7

B.

Tom.

ODprOBIlR.

Filled by mtilberrr-lilte tumoDT. gnm-
IcnJinE into ^""^

U
H

17

18

H.

r.

7
7

R.

I.

L.

B.

L.
K
L.
R-

1 monlh,

8 JMI*.

Ditto
1H moothg.

intto.

NOTU.

1 iucbo.
aindin.

8 India.

nino.

4 ln>-hni.

5 IncliH.

Kor™«L
Diito.
MoitDiL

NonniL
Wlto.

Ditto.

NonnJ.

Kormd.

Filled with cemmnL

ConUini thiclt cueow di>cturg«. . .

le

H.

S3'

80
81

ai

u.

F.

9
BO

L

B.

L.

DiUo.

flyeuj.
3 wck..

fl dB)».

4idch«.
3 inch™.

Ditto.

NORUL

No lobe.
Sormti.

M.mbrw)e tl.i<4a»d and polpr , ■

N::™::i"r

R.

I'ncerUin.

Slncho.

Ditto.

Dty ind conlnKted.

88

H.

"

a

8y.«i

4 Inchea.

MoroKtl.

u

V.

38

R

amoDtbs.

8 1ncb«>.

NoniuL

as

t.

SO

L.
«-

L.

mtio.
14 run.

Ditto.

0 inch«.

None.

liDcb.

Ditto.

NornuL

Ditta

BEaiSTBT OF EAB CA8B8.

117

lof MHnbnxiA T^mpftnL

d thickened.

Bflaeu.

1 and opaque.

owing to thickening of
f canaL

eieeD.

ipaqne ; like parchment .
1, opaqae, and collapsed. .
X circumference ; opaque in

)paque, but polished.

Middle Ear
and Eusta-
chian Tube.

InflaUble.

ad opaque,
d thickened.

hickenedf opaque ; an aper-
e of pin*8 head anteriorly,
' vibrating bubble.
1; a white triangular de-
front of malleus.
!, opaque, vascular. . . .

I thickened.

; bk)od-red superiorly. .

1 and opaque, showing pre-

I, vascular ; large aperture
rly.

, dense, white, thickened ;
re of vibrating portion a
in, depressed spot, with ele-
argin from previous ulcer ;
h drde inferiorly.
ck, opaque, pearly, dimmed.
I and opaque.

hideoed.

Uninilatable.

Ditto.

InflaUble.

Inflatable.

Pain.

Originally in

apertures

for earrings.

Kone.

OccasionaL

Soreness and
itching.

On pressure.

Ditto.

Inflatable.

Uninflatable.

Inflatable.

Inflatable.
Inflatable.

Uninflatable.
Inflatable.

Inflatable.

Inflatable.
Ditto.

Tumour be-
comes pain-
ful occa-
sionally.
Previous.

None.

Severe pain

at night

originally.

Came on

with pain.

Ditto.

None.

Ditto.

None.

Noise.

None.

Tinnitus.

Tinnitus.

• . • .

Tinnitus.

. * •

None.

None.
None.

None.

Ditto.

Throbbing.

....

. * . •

....

State of
Throat

Normal.

Normal

Normal
NormaL

Normal

None.

Pain on ac-
cession of
cold.
None.

Great, like
roaring of

Ditto.
In head.

Previously.

None.

Like steam
engine; in-
creased by
cold.

Ditto.
Loud.

Ditto.

NormaL

Normal.

....
NormaL

NormaL

....
NormaL

NormaL

Tonsils en-
larged.
NormaL
NormaL

Diaeaae attri-
buted to

Piercing
lobee.

...

Cold.

. • • .

Erysipelas
of head and
face.

....

....
. . • .
Severe cold
day.

Cold.

Ditto.

....

A blow on
the ear.

Belaxed.

Membrane
red and
relaxed.

Tonsils en-
larged.

Scarlatina.

Scrofula.
Occupation
oflaundrees.

Ditto.

Cold.

Cold and
pain in
head.

....
Scarlatina.

BEfllSTRT OP EAH CASES.

Na.

B«.

Ae.

Ud.

2:

H»rto,

t>iBul«.

».,.-»..

«„..^^^c-.

86

H.

i£

L

a jein.

None.

NorauJ.

u.llv, cutieuLu on exposed ■uifuni

87

F.

1».

R.
R-

Kilo.

GmoBttas.

4 iacbM. on
rcmoviog
diwbir^
liDCb.

Ditto.

Noraul.

from »ntetior wall.

Telluw diicb^Ee t Urge fUtitir pofy-

piuoccuplisrundiu.

Dtta.

TaachinB.
Siocbw.

VeryimalL
Komul.

D'tto

S8

T.

38.

ft.

amontlu.

Eol.rg«l, diy, «.l3-, t^nkiib ; paitl-
lent diKturgf^ with ur babbles.

39
M

41

P.
H.

F.

IB

GO

I.
K.

I.
L.

nuio.

4 m'ouUu.

NOM.

Ditto.

Nurmal.

Normd.

Helis (.l,lii»™l«l

Filed with laseoM depodt. ....

N»rn..l

Killed bv inietl polvpiu; ditchain .
A n,.re .Ut, d^-, ,c*ly. plugged iri<k

bani Krumcn.

ii
43

T.

H.

30
46

L.
L.

14 d«y..
6 monlhi.

Glncbm
None.

Nocmil.
Norm.L

cbarKB b^n three dayB ajtcr pun,
wbidh then ce»ed.
DiminiKbfd. loiv«-extr..mit.yvwcuUr,
■Helling mid pain in nusloid ivgkia

45

U.

36
IS

R-

K.

15 )-™ni.

Now.

None.

Normd.
NgrDUd

Wall< thickenrd, opaqne ; diichwn.
Diy, end devoid of conunen . . .

46

r.

50

B.

3 monlba.

t foot.

NonnmL

Filled b7 dirk, inlckr cenuiuQ. . .

47

T.

"[

L.

L.

11 ««ni.
1 muuth.

2 >ncb«.

Nomxl.
Nonn^

Dry, devoid or cerunien

48

M.

iO'

E.

L.

ISyem.

e incU«.
Nunc

Ditto.
Nonnd.

Dry, membrane pinkish io&iriotlr. .

49

u.

17

60
fil

F.

44

B.
L.
D.

DiUo.
6 J-™™.

Toudiing.
Blncbca.

Ditto.

Lobe nkcntcd

(mm diKlmrge.

Noim^.

Thickened, okented, fllM with die-

Devoid rfcoramen

F.

4B

D.
L.

I8d.j»

20)-«ra.
Ditto.

Nooe.
Touching.

liDch.

NonD>L
Nomud.
Ditto.

Dry. ecaly, no certmun j origioallr

idiMhergF of bloody fluid.
Filled by condylomaU i Mid dli-

cherge.
Dry, dev(M of cerumen.

64

H.

7

L.

iDMntli.

SiDcbtft

KonuL

BBOI8TBT OF EAS CASES.

119

IfiddleEar

1 of Membrana Timpani.

and Eusta-
chian Tube.

Pahi.

Moise.

Bute of
Throat

Disease attri-
butedto

at time of note, owing to

None.

....

Normal.

Scarlatina.

x>lypii8 and discharge.

rtiaUy visible ; whitUb,
ned.

• • a a

Ditto.

'dear and perfect . . .

None.

Like bells.

Glands en-
larged ; the
voice very
harsh.

....

inferiorly ; reddish grana-

Ditta

Ditto.

....

. • . .

Bpfvwing over it.

opaqae, perforated. . . .

Inner wall of
tympanum
seen through
aperture.

None.

...

NormaL

Cold.

• • • •

Ditto.

• • • •

....
Bellows.

....
Normal.

• • . •
Fever.

unkisb, perforated in centre.

At night
Occasionally

None.
Buzzing.

NormaL
Normal.

• • * .
Sitting at

rhite, mottled, somewhat

Uninflatabie.

flteiiorly.

open win-
dow.

lacular, perforated inferiorly.

Inflatable;

Originally

Tinnitus in

Normal.

Cold and ex-

membrane

violent at

ear and

posure.

1 pinkish.

night

head.

ynn. pinkish tint ....

Uninaatable.

Severe, with

Frying and

Normal.

Suppressed

pulsation.

buzzing.

perspira-
tion.

1, opaque, has lost polish.

Uninflatabie.

None.

Tinnitus.

Normal.

....

que, thickened posteriorly,

Inflatable.

Much at

Beating in

Normal

Sleeping in

k anteriorly.

night

ear and
head.

wet clothes.

; a dense white crescent

•9

Uninflatabie.

None.

Singing.

Normal.

....

7'

gprannlar.

Severe.
Slight, in-

None.
Tidal.

Normal.
Normal.

. • • •
Heats and

with red vessels; malleus

discernible; its site marked

creasiadon

colds.

paqae line.

sneezing.

ed

Ditto.
Occasionally

Ditto.
Like water-

. . . •
Normal.

. . • •
Fever.

thickened, irregularly spot-

Eustachian

colar superiorly.

tubes free ; air
has a whist-
ling sound.

violent

fall

ok over outline of malleus.

Whistling
sound.

Ditto.

Ditto.

....

....

1, vascular, perforate at

Mucous dis-

Originally.

None.

Normal

....

charge from.

I and opaque, vascular

Only occasion-
ally pervious
to air.

Occasionally

Buzzing and
beating.

NormaL

....

Violent

Buzzing.

Normal

Wet and

V m

^

cold.

None.

NormaL

....

; defined, crescentic opacity

r-

jiink colour.

* * a a

Inflatable.

a a * a

None.

• • • •

None.

• • • •

Normal

Cold.

120

RBOI8TBY OF BAB CA8B8.

Ko.
of

66

56
67

68

69

GO

61
62

63

64
66

66

67
68
69

70

71
72

Afe

F. '25-

Ear ! Dnrmtion

affec-' of

ted. , Diaeue.

Hearing
Dirtaaoe.

R.
L.

^•'^^l R.
F. 50 R.

H. 40

F.

F.

20

]6<

14

M. 50

F.

H.
F.

25 <

25

M. 40

I

M. !68
F. 14
F. 50

i

M.

F.

16

21

F. !60

L.

R.
R.

L.

B.
R

B.

R.

R.
L.

For years.

3 months.
Ditto.

1 month.

8 inches.

5 inches.
4 inches.
Normal.

None.

5Iany years.
Ditta

8 years.

Ditto.

4 inches.

2 inches.

3 months. Impaired af-
ter fits.

State of Aariele.

Normal

Ditto.
Normal.
Ditto.
Hard, elevated,
sensitive cica-
trices on helix.
Normal

NormaL

Ditto.
NormaL

2 weeks.

6 months.

Xw • • • •

2 we^s.

2 years.

10 years.
Ditta

L. iMany years.

Ltm \ ....

L. 8 months.

R.

L.
B.

10 years.

10 years.
14 years.

6 inches.
Toaching.

Ditto.

Toaching.
None.

None.
3 inches.

Touching.
None.

Touching.
None.

Ditta

NormaL
NormaL
Normal.

Ditto.

Normal.
NormaL

Normal.
Ditto.

Normal.
Helix wanting.
Flattened by long j
pressure of a
hand ; helix
obliterated.
NormaL

NormaL
NormaL

State of Bxtoml MeatBs and GanaL

Dry, no oemmen. • •

Dry and scaly. . . .

Dry.

Filled with honey-like
Mucous secretioo, «^*»>»«^«"mg air |^
bules.

Diy

Dnr and white.

Ditta

Contracted, walla thickened ; Bki
with crusts of insplasated mQCOS;
has occasional discharge.

Membrane thickened and pulpy ; pio>

fuse discharge.

NormaL

NormaL

Pinkish at lower extremity. ....

Impacted with cerumen; the cntide
of canal and membrana tympani re-
moved witli it.

Filled with hard oenunen.

Coated with discharge.

Drv, devoid of oemmen.

Ditto

Dry

Only size of crow-qutU

Walls, touch resembling a slit ; lin-
ing white, thickened, exuding dis-
charge ; bottom filled with hard
cerumen.

Walls white, thickened ; coated with
discharge.

Filled by discharge ; granular po^jpoa.

Dry, devoid of i

BBQISTaT OF BAB CA8I8.

121

if Membnna TjmpanL

Middle Ear
and Eusta-
chian Tube.

Pafai.

Moise.

State of
Throat.

Disesseattri-
bated to

, opaque ; atheromatoua

Uninflatable.

None.

like car-

Normal.

• . • *

of crescent shape poste-

riages.

ottled anteriorly ; polished.

and opaque.

Ditto.

Ditto.

Ditto.

. . • .

....

, collapsed, pinkbh. . .

None.

Occasional.

Normal.

Cold.

vascular ; large aperture
r.

Inflatable.

....

• • • •

NormaL

• • • •

iqoe, dim ; a cicatrix in

Inflatable. Occastooally

Incessant,

NormaL

Fall on back

part running from above

like steam-

of head.

ds, which becomes red on

engine.

against

; bad hsmorrhage from

street rail-

falL

ing.

ollapsed; centre natural;

Occasionally

....

NormaL

....

lite opacity^ with deflned

severe.

nd inferior circumference.

• left, but thin, and of a

Inflatable.

Ditto.

....

....

....

k colour.

; coe-half destroyed infe-

Memb. pulpy
and florid red ;
air cannot pass
into tympa-
num ; trying
to inflate red-
dens memb.

None.

Great and
continuous.
Ararecaae.

NormaL

....

inly destroyed ; a thick

Ditto.

Ditto.

Ditto.

• • • •

....

itch containing malleus

Ickened on both sides. .

NormaL

Fall on her
head.

rid red, granular. . . .

Lacerating.

Blowing.

NormaL

Cold and
exposure.

rith crescentic opacity at

Inflatable; in-

Intermitting

None.

NormaL

• • • •

;e; polished.

creasing co-
lour in H. T.

acnlar; thickened, opaque,
skened; pulpy from pres-

Uninflatable.

• • • •

Buzzing.

NormaL

Influenza.

XfftA.

None at pre-
sent

. . « .

Normal.

Scarhitina ;
glandular
swellings.

opaque; white, thick. .

None.

Tinnitus.

NormaL

....

opaque ; skim-milk co-

Ditto.

Ditto.

• • • •

....

and opaque.

Normal.

ally visible. ...

Pam.

....

NormaL

....

te, mottled with pink. . .

OocasionaL

Buzzing.

NormaL

A cold
draught

skeoed, white. ....

UninflaUble.

• « • •

....

NormaL

....

None,
liond, tidaL

Normal.
' NormaL

....
....

|iaed, thickened, opaque.

Uninflatable.

• • • •

BtGUTBT or BAB ClSBft.

>r{

SO ; H- 13

87 , F.

H

7. 8 I

Imiwltd with d>rit tat

Xoraul- Dnr, uiJ drtnd ot «

Nunoal. Dry and lah ; dp ot

Touchini;.

Hisid Tfd ; bony protubnueB K-
Mchnl >Dl«iarij i '

Long utd tortnuiu, dcroid

while ■■ "
Diilo

1 1 Tran.
Ditto.

NarmaL ' Drr ; lining
IHlto. I Fillnl wllb >

I Diilo.

BBGIBTBT OF BAB CASES.

123

lUddleEar

to of Membnna T^mpuil.

and Eusta-
chian Tube.

Pafai.
Numb.

Moise.

State of
Throat

Disease attri-
buted to

1, thickened, pink; small slit

Inflatable.

Loud and

NormaL

Sudden cokL

nfiy ; air whiatlea through.

continuous.

llapsed; dense white; trian-

Ditto.

None.

Bellows.

• • . .

. . • •

.pertare anteriorly, with in-

edges ; red membrane of

ear seen through.

> layer white, thickened,

Pains in

Severe; ver-

Normal.

. • • •

adherent to cerumen.

head.

tigo.

In head.
None.

Buzzing.
Blowing ;

Normal.
NormaL

Headach.

. • . .

1; slightly thickened ; mot-

Uninflatable.

ith white spots ; vascular

giddiness.

malleus.

h In front of malleus. . .

Pain.

Stuffing.

NormaL

Cold.

dtak red ; malleus imper-

1

In suppuration

Great

Throbbing.

Normal.

• • • .

1, thickened, opaque ; mal-

Uninflatable.

None.

Whizzing.

. . • •

. . . •

ry prominent

with whitish exudation. .

• • • •

• . . ■

NormaL

• . • •

1, thickened, opaque; slightly

Inflatable ; red-

Pain and

Buzzing.

NormaL

Cold.

; dense yellow spot l>efore

ness of M. T.

soreness.

1.

increased ; re-
port on inflat

,piiik

InflaUble.

Soreness.

Buzzing.

Belaxed,red.

....

t polished.

Inflatable.

Originally.

A grating.

NormaL

....

d, opaque, vascular snpe-

Ditto.

....

Ditto.

. . • •

....

d,

Rheumatic
Soreness and

Hammering.

« • •

Normal.
Normal.

Cold.
Scarlatina.

opalescent

InflaUble.

itchiness.

^pnipy

Inflatable.

Pain.

Buzzing.

Normal.

. • . •

None.

Singing.

NormaL

. • ■ •

Ditto.
None.

Ditto.
None.

. • . •
NormaL

. . * •
Diving in

Promontory

plainly seen.

the sea.

id, opaque, pinkish crescent

InflaUble.

Slight

Tinnitus.

NormaL

Cold.

1y; midleus prominent.

1, unpolished, white above,

UninflaUbk.

None.

Ditto.

....

....

am ; malleus prominent

ipot anteriorly, thin, trans-

InflaUble; in-

Originally.

Bellows.

NormaL

Cold.

projecting like elastic mem-

creases pro-

n ulcer of cornea.

jection.

d, vascular; aperture near

InflaUble.

....

None.

....

. • . •

r malleus.

1, red, thickened

InflaUble.

None.

Tinnitus.

Normal.

....

id, opaque ; several vascular

UninflaUble.

None.

None.

Normal.

Typhus fe-

ma; pink crescent inferiorly.

ver.

1 thickened.

InflaUble.

None.

Tinnitus.

Ditto.

...

id. opaque, pearl-coloured.

InflaUbl&

. . • •

Tinnitus.

NormaL

. . • •

1, unpolished ; malleus pro-

UninflaUble.

None.

Waterfall.

Normal.

Influenza.

; yellow, atheromatous de-

iferiorly.

1 ; white spot in centre.

Ditto.

Ditto.

Ditto.

• . . •

. . • ■

lertore posteriorly. . . .

Mem. villous.

None.

Ticking.

C. tonsillitis.

Cold.

id duIdv

Ditto.

Singbg.

....

ID dense white

None.

NormaL

• • tt •

e e a tt

like skimmed milk. . .

• • • •

124

BB0I8TRT OF SAB CASES.

Mo.
of

96
96

97

98

99

100

101

102

108

104

106
106

107
108

109

110

111

112

118

F.

F.

F.
IL
IL

M.

Yn.

26
16

10

7

40

Ear I Diintkm
•ffec-. of

ted. : DiMtte.

B. ; 4 months.
1 month.

{

F.

F.
F.

F.
IL

F.

F.

F.

F.
F.

87'

62

14 <

80 <

16
26

10
21

16

I

60

20

12

R.
K.

K.

B.
K.

L.

2 months.
2 years.

3 months.

• • . •

8 vears.

Years.

Ditto.

12 years.

K. j Ditto.

K. I Since child-
hood.
R. 4 years.

L.
L.

R.

L.
R.
L.

R.
R.
R

L.
L.
&

L.

R.

Ditto.
9 years.

Ditto.

6 months.

• • • •

14 da vs.

6 years.

• • • •

10 years.

2 years.
1 year.

7 years.

• • •

Tears.

4 years.

Hearing
Distance.

1 inch.
Touching.

Ditto.
None.

None.
2 inchea.

1 inch.

4 inches.

None.

None.

None.

8 feet

None.

3 inches, in-
creased by
discharge.
1 inch.
None.

Touching.

None.

1 inch.

2 inches.

1 inch

None.

2 inches.

Touching.

6 inches.

1 inch.

Ditto.

1 inch.
Tooching.

State of Awkle.

NonnaL
NormaL

Ditta
NormaL

Ditto.
NormaL

Ditto.
Normal.
NormaL

Ditto.

NormaL

Ditta
Normal.
NormaL

Ditto.
NormaL

Ditto.

NormaL

Ditto.

NormaL

NormaL
NormaL
NormaL

Ditto.
NormaL
NormaL

Ditto.

Normal.
NomaL

State of]

Dry and scaly. .
Pink, moist, some

Pink

Filled by yellow, bloody

FiUed by insptasated diaduuge. . .
Normal

Ditto.

NormaL

FiUed by caseona matter,

air globules.
Filled by thick discharge.

Enlarged, dry, pinkish ; no nmimi

Dry, scaly ; normal in oolovr. . . .

i
I

Coated with discharge.

Coated with fetid discharge. ....

Normal •.. •.•••

NormaL

Filled with oermneo.

Filled with oerumeo. ,

NormaL

Dry ; no oemmen.

NormaL

NormaL

Dry, pinkish ; no cerumen. ....

Coated with discharge^ which intannilii

Filled by sanioos diacluuge -
polypus attached poateriorly.
No cerumen. •••...«

Normal.

White, polished ; no
No cerameo ; pinkish.

BSaiSTBT OF SAB CASES.

125

B of Manbniw Tympani.

Middle Kar
sad £atta-
chianTube.

Pidn.

Moise.

State of
Throat

Disease attri-
buted to

i ; streaked with red. . .

Inflatable.

None.

Tidal.

Normal

Cold.

!ep red cresoent inferiorly ;

InflaUble; in-

Dull

BeUows.

Normal

....

scarlet vessels on sorfaoe,

creasing red-

ig from point of malleus.

ness.

n light pink.

Ditto.

Ditto.

Ditto.

....

. a .

ly removed.

White bubble

Great origi-

. a a •

Normal

Scarlatina;

in Eustach.

nally.

f^ial pa-

opening.

ralysia.

kened ; red and yellow spots.

....

... a

Red.

....

pinkish inferiorlj ; bulged

Inflatable.

None.

None.

Normal

....

Is in pockets.

d and white throughout. .

Uninflatable.

Ditto.

Ditto.

....

....

d, opaque ; like molfed glass.

.....

None.

None.

Normal

....

d, opaque ; small aperture

InflaUble.

Pain.

None.

Normal.

....

) Eustachian opening.

troyta.

Memb. thick;
exuding blood.

None.

None.

....

....

Inflatable.

Slight at

Noise in-

Normal

Draught of

ots ; malleus projecting,

/

present.

creased by

cold air.

bjr white line.

cold.

aeotre ; white crescent infe-

Ditto.

None.

None.

....

. a . .

thickened, and granular. .

Uninflatable.

... a

None.

Normal.

....

thickened posteriorly ; vas-

Inflatable.

None.

Singing.

Normal

Cold.

iteriorly, with small valvu-

tan.

Bd colour.

Ditta

Pain.

....

....

... a

J, opaque, dense white. .

Inflatable.

• • • •

Chirping.

Normal

Cold after
parturition.

ickened ; slightly vascular,
f trotD removing cerumen.

• # • e

• • • •

• • • •

* • • •

i, opaque, bluish white. .

Inflatable.

None.

HdaL

Normal

Cold.

Ditto.

Loud reports

....

Ditto.

wrinkled ; a uniform pink

Inflatable; vas-

Pain 'in-

• • • •

Normal

Wet feet

cularity of M.

creased

T. increased.

at night

and, deepening in centra;

L

Inflatable

None.

None.

Normal.

....

Inflatable.

Deep-seated.

Normal.

Paralysis of
fkce; ptosis.

^"•* •«^^^^B *i^*^^*

pink ; aperture in centre,

Mem. deep red;

None.

None.

Normal

Fever.

ite, thickened edge ; malleus

shadow fh>m

ipwards and backwards.

edge of rent

que, with red spot in oen-

Severe.

Tinnitus.

• . . .

Bathing.

lUeos not discernible.

None.
Flowing of

Normal

... a

Scarlatina.
Head shaved

, thickened ; irregular on

Uninflatable.

In ears and

i yellow inferiorly ; whitish

head.

water.

bDow, irregular ; dark de-

Inflatable ;

Pain origi-

Billing.

Normal

Ditto.

itericdy ; white streak fklls

M. T. projects

nally.

illeus.

in pouches.

ertore anteriorly ; its edge

Uninflatable ;

• • • •

Buzzing.

Normal.

Scarlatina.

bickened, inverted.

rose-coloured.

1, pink, and white. . . . SlighUy infl.

None.

Bin^^.

Normal

....

126

BE0I8TRT OF EAR CASES.

No.

of

Cwe.;

114' F

I

115 M.

116 M.

117

118

119
ISO

ISl

122

128

124

126

126
127

F.

F.
F.

F.

F.

A«e
Yr».

Ear

aflec-
tcd.

- - -

' ~l

Dantkm

of
DianM.

{, R. I 1 year.
: I

J-j» I • • • •

12 R. 6 months.

r

I

4ii

[

8<

60

26

16

!
i

r

80

F.

M.

M.

F.
M.

22

50

18-

80 •
18

R. 6 months.
L. 18 months.

R.

R. I 6 months.

Ldt • • • • .

Tears.

&

R.
L.

R

L.

R.

L.
L.

R.

R.

L.
L.

R.
L.

1 month.
10 years.

6 weeks.

6 yean.

8 years.

6 years.

Hearing
Distaooe.

State orAwlele.

2 inches. iProtuberanoe in
front of tragus.
Normal
Normal.

Touching.
2 inches.

None.

Touching.
Touching.

4 inches.
2 inches.

20 years.
9 years.

1 year.
10 years.

2 months.

None.

2 inches,
linch.

2 inches.
4 inches.

I inch.

6 inches.

Touching.

Ditto.
4 inches.

6 inches.

None.
None. I

14 inches.
Touching.

None.
8 inches.

Touching.

NormaL

Ditto.
NormaL

Ditto.
NormaL

Ditto.

Normal.
Ditta

NormaL
Ditto.

NormaL

Ditto.

NormaL

Ditto.
NormaL

Ditta

Normal.
NormaL

Ditto.
NormaL

Ditto.
NormaL

Ditto.

State of

Filled with mooo-paruloit disduugeu

Small polypus attached anterioriy.
Filled by

tragus.
Hoist, polished.

Ditta

Veiy large ; lining xtormal, bat dry.

Ditta

Dry, scaly, containing crusts of inspis-
sated discharge, which ceased klefy'.

Coated with a thin discharge. . . .

Normal

Ditta

Normal

Ditto

Had discharge oo three

Ditta ,

Dry, devoid of cerumen.

Ditta

NormaL

Ditto.

Impacted with hard -...«„. . . .

Dry and scaly ; had diachai^ge — »*fl
two years aga

Dry, red ; no cemmeo. ••..,,
Dry ; membrane pinkish.

Dry

Dry and scaly.

Ditta

I

BKQISTIIY 0¥ BAB CA8B8.

oflInbr«i>t>»p<ad.

MtddleEar
cblanTuba.

Pdn.

MolM.

Hate of

nueh thickoied and ool-

NODt.

llnnitui.

Ditto.
Pumping.

Nooa.

KUo.
Singing.

■nnniloa,
(rare).

Singing;
Ditto.

None.
Mtio.

NomuL

HoniaL
Normal

No'n^l

NormaL

NonnaL
Normal.

Cold.
Cold.

Inf., H. de<p
red.shiDing;air
biases sqneel-
ing sound.
IKtlo.

Ditto.

Membrane red
pulpy i sha-
dow thrown
by fragmen
ofmem.tyn,

loos, red.
lodatable.

InHaUble.
UninHatable.

UninSaUble.

Inflatable.

Unina'at^bie.

Inflatable; can
pre» out >pol

Inflatable.
Unluflatable.

Ditto.
Inflauble.

Ditto.

Origlnallj.

Originally
•tnigbt

Ditto.
None,

Dltio.

Onaneeaing.

None.
Ditto.

Pain origi-
nally:*^

iterior liair deetroyed, re-

M glau : zona of pinkiib
ity inferiutlr ; dense white
;wB«n point of malleus and

right, but colUpsed, want-

erlorhalfdettmved: mal-
Ih a fragmenl of thickened
oa, drawn upwirda and
da.

own. ; «n.ll opening

fil«qoe. mottled with pink,
link, deepening interiorly ;

kim-milk colour. ....
; dense 1 red veaseli over

, <¥*q<K. Uke crumpled
nt

a«:ularily at inferior edge,
opaque, dull ; an elevated
in tower aoteriur porUon.

p.qoe,bntpoli.hrt. . .
irregular on surface by
of ooDcavities and con-
it in centre-, tta edge well

, opaqne, like old pnrch-
. nd etn.ak ovsr mallcua-
, imlisbed, reflwlinB liBlit

-riteofitaattochmi^ol.
Oll«bed,madoredbyinfl.
■Llm-milk colour wbite
lends rrom malleun.
., moUled with white. . .
lied with while ( light re-

iKalar, butpoUabed. . .

Great.

Nono.
Acute origi-
nally.

Mnch (tor-
»erly.

■no^-

None.

On find ac

cea^on.

Ditto.

Uke run-
ning w«er

Ditto.
Atickiiig.

Ditto.

None.

DlUo.
Boiling wa-
ter.
Ditto.
Beating <^-
ginally.
Kito.

NormaL
Noniai

NormaL

NormaL

niniaL
N^ai.

Blow, fol.
towed by

from R, ear.

A severe
wetliDg.

Parturition.

....

BEQUTRT OS Elft CA8S8.

toj

. 50 J

. 30 j

8 monllu.
6 maath).

einchd.

KODC

Konu

diBcbarge.
Kunniri.
Noimtl.

NornuL

Ditto.

FUttea«d b/
NormaL

Ditto.

Ditto.
NomuL

Ditto.
IHtto.

Scily ernption «xl«dlD|K into nu
tilled by- diadiu^ ; mnrnll polypoi

from upp«r wall ; luver rtge ulatH.
t'uat«d vilb diw-htirge and cnuia,

Dn-, ililniDti, vucuUl

Enlarged ; filinl with khoroiu M

chat({«; memti. white and Uucfceaa

Kll«d with oily fluid

Korcnal

A Kale of dark emunen at bouom.
EDlargcd ; covered with dischaigt;

polypua, attached aoterioiij.
Drj ; bad diachargn fnjiooMfy.

NoniuL

CoolracUd ; coated with dischAJgSi .
Thlekaned ; lining membrane whitiik

KormaL

Normal. .,,.,

Nurmal ; very
mobile.

EcEematoua.

te ; nuall ctiWnsia rataiorij*
'Tbickeoed ; bloody diaduugv. . ,

LIniiiK thickened i dry, md. .
nUed by puruleol ducharge.

Lining [unk ; poliabod. .

Long and toitaoog ; dly.
Nanvw and elliptical. .

BB0I8TBT OF BAB CABB8.

189

9 of If wihriiMi Tywttftad.

Middle Ear
and Eusta-

Fain.

Noise.

State of
Throat

DiseaMSttri-
bated to

khkkeiied ; white, bat poUiihed

Inflatable.

Itching.

None.

Normal

....

None.
Ditto.

Normal

....

Scarlatina.

....

with scaly inonutatioiL

... •

....

I uziiform sheet of opsdty. .

Originally.

Giddhiess.

Normal

Erysipelaa.

arfonte ; air globule reOects

Inflat. ; water

....

....

Nonnal

....

I antero-inferior portian.

passes throuf{h.

id, dense, red

InflaUble.

Originally.

Tinnitus.

Normal.

Influenza.

pinkish, vascular. ....

InflaUble.

None.

Whistling.

Normal

....

d rsd spots, probably nlcen.

Inflatable.

None.

None.

....

....

■ *va*#**B*

OccasionaL
None.

Tinnitus.
None.

Normal

• • • •

Scroftila.

• • • •

iNnd bj white band ; a de-

Unfaiflatable.

spot superiorly.

ickened ; a large aperture

Promontory

None.

None.

Normal.

• • • a

n\y.

presents at
aperture.

d, opaque, rascular. . . .

Uninflatable.

Ditto.

Ditto.

....

• • • •

red ; bulged outwards. . .

Gurgl sound.

Throbbing.

Hammering.

Normal

Cold.

red : malleus unseen. . .

Severe.

Ringing.

Normal

Severe sy-
ringing.

■aoculent.

Stinging.
On flrst ac-

* % 9 #

Normal.

Cold.

; streaked with bright red

Uninflatable.

Buzzing.

Normal.

Cold.

Facial Paralysis.

cession.

1; traversed by pearUcoloured

....

Rhiging.

Normal

....

id below; bright pink above.

Tymp. cavity
uninflatable.

Most severe.

Drumming.

Normal

Cold.

*, like conjunctiva of eyelid.

Uninflatable.

None.

Ticking.

Normal.

Scarlatina.

bulged into meatus ; dis-

Ditto.

Ditto.

Ditto.

• • • •

• . . •

fron.

1, opaque above, pink below,

Inflat.; memb-

None.

TidaL

Nonnal

....

lehind.

made vascular.

InflaUble.

Ditto.

Ditto.

• • • •

....

Inflatable.
InflaUble.

None.
Violent

Uke bells.
Throbbing.

Normal
Normal

Cold.
Cold.

ruptured.

9d ; red over malleus. . .

UninflaUble.

None.

Steaming.

Normal

Cold.

Ch vesicular projections.

InflaUble.

Ditto.

Ditto.

....

. . • .

r, like ripe raspberry. . .

Slight

None.

Red.

....

nt ; white ring inferiorly. .

Uninflatable.

Rheumatic.

Tidal.

Nonnal

. . . •

irts removed.

M. granular.

Ori^nally.

Hammering

Normal

Cold.

id, pearlaceous.

InflaUble.

None.

Singing.

• • • •

....

>Ctled with white

InflaUble.

Occasional.

Buzzing.

Red.

....

as in aquo-capsnlitis. . .

Ditto.

Ditta

Ditto.

....

. • . .

'dsstroyed, ossicles and rem-

Membrane

None.

None.

Normal

Small Poz.

Irawn upwards and back-

thickened,
red.
Ditto.

1 anteriorly; malleus unseen.

Ditto.

Ditto.

• • • •

• • • M

1 ; white ; malleus projecting.

Umnflatable.

Original

Musical.

Normal.

Cold.

1, white, pulpy.

InflaUble.

Ditto.

Ditto.

....

....

vascular, with deep-red spot

Inflatable.

Original

Rustling.

Normal.

Fever.

re of anterior part.

lerture inferiorly. ....

Memb. villous.

None.

Boiling.

Normal

• • • •

E. tube closed.
InflaUble.

Ditto.
Severe.

Ditto.
Buzzing.

....
Nonnal

Cold.'

m pink

1, Ugfaly vaaeolar. . . .

Unlnflatabk).

None.

Ditto.

• • • •

•

....

BBOnTBT or UB CASB8.

r I

. 38 J

■■•{;

4 daj*.'

NonnaL
KonnaL

Tonching.

Ditto.

Swall<Mi. nd, u
painful.

NaniuL

Ditto.

1 Inch.
Tooching.

Helix wuiling;
porpla.

Ditto.
Eiyapeiiloiu

miulold nfpBB

ly«r.

ContncUd; thickoMd ; dlsdw
nUcd completely with Urgo pd
which project* eiwrcilly.

Brown-Twi, dry. ,

Dij, sciij, piok. ......

Coatractcd ; whitish diachaiga,
Monnsl ; nevtr had discharge .

Ditto.

NonnaL

D7.

nilfld with poi atid Bir bobblo
Containa thto mnco-pnmlMtdki
No cgnuDBO ; pinkiah. . . .

NormaL

Teiy red ; bad diaebarge crigto

Dry and poliahed.

Swollen ; coalAt with lymph and

purulent discharge ; Blled by ■

of Indian com.
nr; •.<»nmo.

Oweotu toCToacbmcot pottniiwl

charge originally.
Dry; no cemmon; previooi diM

Filled with diacharge umI iIt gli

Dry, waly.

Filled with discharge. . , .
Enlarged ; nneaml with diMlM

Dry, with membraiM tomgitol

Filled bj NTeral aoull all hi aw
Conlruted ; filled irith craMa i

nular inn^orly ; a thin acala •

projecting.
Filled by discharge and air glo)
Filled with scales and cenm^
Filled with caaaea. ....

Normal

Saniooa discharge troni. . . .
FUbd with tcaUa and MrniMn.

BB0I8TBT or BAB CASES.

131

Middle Ear

of Moabniw T^peaL

and Eusta-
chian Tube.

Pabi.

Moise.

State of
Throat

Diaesae attri-
buted to

None.

None.

None.

None.
Tidal.

None.

NormaL

• • • •

NormaL

....
....

Cold.

1, opaqoe, poluhed. . . .

Uninflatable.

notUed, poliahed. ....

Inflatable.

Ditto.

Ditto.

• • • •

• • • •

Soreness.
None.

None.
Blowing and

Normal.
NormaL

• • • •

Scrofula and

Ite ; thickened ; clear, de-

TnflaUble in

spoU behind malleiia, and

pockets.

singing.

spine dia-

to Boatachian tube.

ease.

inuned-milk coloor, with

Uninflatable.

Ditto.

Ditto.

....

» • • •

mple Interiorly.

m pink.

Pain.

Singing.
Confused.

NormaL

^tlj opalescent. ....

Inflauble.

None.

Normal.

• • • •

Fever.

a palaating rent anteriorly.

Uninflatable.

Intense.

Reports.

Red.

CokL

UaiMed, opaque ; malleus

UninflaUble;

Oocamonal.

Buzzing.

NormaL

• • • •

• • • •

malleus red.

tch anteriorly.

; white below, red above.

Ditto.

....

Ditto.

....

• • • •

i, opaque, like old parch-

Originally.

Buzzing.

....

Injuiy.

rascnlar above.

; a dense purple red, but

Uninflatable.

. . . •

Tinnitus.

Normal.

....

; malleus prominent

1; small aperture inferiorly.

Ditto.

....

None.

• • • •

Typhus.

Intense.

Buzzing.

NormaL

Foreign

jrmpani found coated with

body.

) lymph.

; opaicity inferiorly ; and

Inflatable.

None.

Running

NormaL

IMving.

In concavity posteriorly.

water.

, opaque ; irregular, clear

Ditto.

Ditto.

Ditta

Ditto.

• . • •

m posteriorly.

, thickened, opaque ; gra-

None.

Tinnitus.

....

Scarlatina.

centre.

; perforate opposite Eusta-

Inflauble.

• • * •

....

Normal.

....

leoing.

ckened ; orange red infe-

None.

Sawing.

NormaL

Stupidity.

rossing lower part

1, opaque, vascular. . . .

OccadonaL

• • • •

Ditto.

«...

nred, rugged, granular. .

UninflaUbie.

None.

Tidal.

Normal.

. • . .

•milk oobur ; white cres-

Inflatable.

Ditto.

Ditto.

. . • .

....

iriorly.

nred, polished. .....

Originally
at night

* # a e

Normal.

Cold.

ilUeL

Originally.

• • • •

NormaL

• • • •

id.

Uninflatable.

Originally.
None.

Tinnitus.
None.

Normal.
Memb. red.

A blow.

» • • •

rhite ; perforate posteriorly.

eorrugated, with clear spots.
•milk colour ; spotted with

• • • •

Inflatable; M.

• • • •

None.

Tidid.*

Normal.

Cold.

red over malleus.

T. reddened.

i opacity below ; white

Ditto.

Ditto.

Ditto.

....

• • • •

roas.

potteriorly.

Inflatable.

• • • •

Tidal.

....

e e • •

■red ; mottled with white.

• • • •

. . • •

TonsiUen-

Cold.

largjrf.

l2

BKOIBTBT OF SAB CAMtB.

ITS

180
IBI

m

ISA
1M

:b

W7

1 88
ISO

IM
101

Its
m

1«S

i»e

197
198
199

100

M.

F.
11.

H.
F
F.

v.

F.
U.

M.

H.

U.

H

y.

U.

F.
M.

M.

M.
M.
P.

Ti«.

Jfi.

10
!0

to

13

U
10

n

no

10

so
flO
SI j

40

I7J
10 1

11

1.

R.
1-
IL
B.

I.
L.
R-
L.
B.
1-
B.
L
R

B.
R.
L,

R.

L.
R.

L.
B.
S.

L.

i

L.
R.

1.

B.

T.
B.

L.
R.

B.

L.

SS22.

■Mxtflaikta.

MaM or EalMial Ifaatna a*l »

JiDonthi.
lOvran.
Si-™™.
IMtiu.

IKito.
Smonlbt.

Ditto.

Ojtare.

Ditto.
4y™.

Ditto.
It. run.
10j-»art

ISytan.
*y«.™.

10 ynn.

Ditto.

llynn.
Ditto.

lOynin.
Ditto.

6 month*.
ByMM.

ToQcUt*.

1 ioch.

Sooe.

ToochiBg.

T™chlDK.

Variable.

N.«.
Touching.

1 IDCh.

Kmm.
lindi.
4inclH<L

N(H.

Ditto.

None.

Dinn.

Twcbing.

Bincbo.

N'OCM.

Ditto.
9iKhM.
Toothing.

Pnaping.
Torching.

KOIM.

ToocUk,,.
Soo(.

Ditla

linehn.
linch.

Siochn.
Touehlng-

Toocblng,

1 root.

tiDdMa

Kormal.

DiUo.
KonnaL

Wtta
MonnaL

NormaL
Normal.

NormtO.
KomiaL
Ditto.
NormaL
Nobtllx.
NormaL

Ditto.
NormaL
NormaL
Impilar.
Jformal; auOoid
gland Bolaiged.
N««>.L
Normal.

Ditto.
Flaltmcd.
Nonnal.

Normal.

Diltu.

Normal.
Ditto.

NormaL

IXttOL

NormaL
Ditto.

HtUi deficient.
Nonnal.

Mo lobe.
IHtto.

NormaL

CoUapnd to m«r« .Kt; unm

Piakub. dry.

t>7.«c«ly.

Scaly; coljcle tfaickeoed. . .
NormaL

Fillod bT hard, dark ocman.
HIW by thick, yellow di>dMi|
WidHwd; lUled »hh cmta. .

NormaL

Ditto

Enlarged ; pink : iu boUoa SOi
dlKhargo and lii glolmkiL

Ditto

Red, dry, and nlj. ....

5=-"':"^."— '

Dry, Kah-; Inlrodoetko of ,
ind™ .pa«nodic coughfa,.

Wriokkd ; Kone emoMa. .
HIM by diachargc , nan ,

rOM with oeranMi. ....

NormaL

Exmriatod with diacfaun ; ■

b1« and polypnt "^
Fillfd with roliddiadianeai^
Exroliated and filled with w

D^«»I«»l7.

Ktto.

Filled with oenmen and Ibi^

BBOISTBT OF BAB CASES.

133

tto of Membnma Tympani.

r ; an ash-grey ooloor. . .

id, thickened, and opaque. .
' opaqoe ; whitish helow. .
below, pink above. . . .
ed; malleos unseen; Facial
lis on left side,
ext layer removed with wax.
IT ; perforate inferiorly. . .
led i pulsating aperture below.

removed

It posteriorly.

streaked with red. ....
sd, thickened ; malleus red.

and thickened

i red and white ; small aper-
ypposite Eustachian opening,
> emits a whistling sound.

iy normal

ed, like crumpled parchment
ed ; opaque crescent fnferiorly.
irly polished ; pink zone in-

^ opaqae, but polished. . .
ed ; bright pii^s over malleus.

oUapsed ; pink above. . . .
led, opaque, vascular. . . .
t, except one clear spot ante>

led, opaque, like parchment ;

7 deejpena at inferior edge,

ver malleus.

ed, thickened ; a triangular,

spot below malleus.

ed, thickened, opaque. . . .

lent; small aperture in centre.

ed, polished ; malleus promi-

dear in middle ; crescent of

y in front.

oly thickened; white crescent

Mfly.

Middle Ear
and Eiuta-
ohiaa Tube.

Inflatable.

te anteriorly.

Md and much collapsed. . .
if opacity, with clear space be-
, ndecting light over large
«, but decreased, and mem-
bolged ontwaid on inflation.
led, ooUapsedy vaacnlar. . .

Inflatable.

Vain.

Severe.

None.

Uninflatable.

Noise.

Like wind.

Ditto.
Tidal.

Inflatable.

Villous.

Very red.

Memb. white.

Inflatable.

Uninflatable.

Ditto.

Inflatable.

Ditto.

Inflatable.

Uninflatable.

Ditto.
Uninflatable.

Ditto.
Uninflatable.

Ditto.

Uninflatable.

InflaUble.

Inflatable ;mal-
leus becomes
vascular.
Uninflatable.

Uninflatable.
Inflatable.

Inflatable.

Ditto.

Uninflatable.
Inflatable.

Uninflatable.

M. hiflatable in

clear spot

Uninflatable.

Severe at
night

None.

None.

None.

None.
Originally.

None.
Originally.

None.

None.

In head.
Intense.

Ditto.

Pain for two

months.

None.

None.

Ditto.
None.
None.

None.

Ditto.

None.
None.

None.

Ditto.

OccasionaL
None.

None.
Ditto.

Originally.

Tinnitus.

like wind.

None.
Like milL

None.

None.

None.
Tinnitus.

Ditto.
Whizzing.

Boiling.

Buzzing.

Confused.

Ditto.

None.

None.
Fizzing.

Ditto.

Rasping.

Tidal

Tidal.

Ditto.

HushiDg.
Ditto.

Tidal, roar-
ing.

Ditto.

Rmging.

State of
Throat

Normal.

Normal.

Normal.
Normal.
Memb. red.
....
Normal.

• • a •

Normal.
....
Normal.

....
Normal.
Ulcerated.
....
Normal.

Tonsils en-
larged.
....
NormaL
Normal.

Normal.

Diseaaeattri.
buted to

Cold.

Ditto.
Cold.

Cold and
exposure.

Crackling.
Ditto.

Buzzing.

NormaL

Normal.

Ditto.
Normal.

NormaL

NormaL
Ditto.

NormaL

Cold.
Cold.

Intempei*.
Syphilis.

« • • •

Measles.

Cold.

• • • •

• • • •

Parturitioa

Cold.

Wearing 1
wet cap.

Fall on head.

Measles.

Ty'phus.
Ditto.

Fractured
cranium.

134 AV1LT8I8 OF BB0I8TBT.

Sess and Age. — From an examination of the foregoing R^stiy,
we learn that of the two hundred persons affected, 101 were
males, and 99 females ; their ages being in the following propor-
tions : — Under five years, 4 ; from five to ten inclusive, 19 ; from
ten to twenty, 63; twenty to forty, 82 ; forty to sixty, 29 ; and
above that age, 3.

Ear affected, — In 27 instances both ears were similarly and
nearly equally affected, in which case a single entry opponte the
letter B was deemed sufficient. In 100 instances both ears were
diseased, but the duration, hearing distance, morbid appearances,
and, in some cases, the cause, varied considerably on each side.
Generally speaking, the ear most seriously affected is that first
noted. In 35, the right, and in 38, the left ears alone were af-
fected. Where the record of but one ear is inserted, the other
was normal. In all cases the entry was made when the patient
first applied at the Institution ; the progress and subsequent ap-
pearances, increased by the advances of disease, or modified by
treatment, have not been taken into account — the object being to
record the exact state in which each case of a given number, taken
without selection, presented.

It must be remembered that all these cases were taken down
at length by a short-hand writer, and that the condition of the
meatus and the state of the membrana tympani, as seen through
the speculum, were the two principal objects attended to. In cases
of manifest disease of the external car, or upon the surface of the
membrana tympani, — sufficient to account for the symptoms pre-
sented,— an examination of the state of the tympanal cavity was
seldom made. The blanks in some columns show that the symp-
toms or appearances to which that particular space is devoted were
not, in those instances, present, or that the statement of the patient
on that point was unsatisfactory. I have lately had a form of regis-
try printed for the Hospital, containing, in addition to the fore-
going, columns for the date, definition of affection, treatment, and
observations, &c., — the tabulated results of which will, I trust, in
time, still further assist the examination and diagnosis of aural
affections.

Dr. Kramer, in his review of my writings in the last edition of
his large work on the Ear, says that I have been illogical in my

STATE OF THB AURICLE AND XBATUS. 135

deductions ; this may, possibly, be the case, but I beEere it will
be acknowledged that, in medical science, one well-established
fact, and truthful observation, is worth a hundred syllogistically
arranged arguments.

Duration of Disease, — The duration of the disease, as well as
the hearing distance, is difficult to tabulate, owing to the variation
in those cases where both ears were affected. In some instances
the patients gave such an unsatisfactory accoimt of their disease^
that the most which could be gleaned was, that they had been
'^ deaf for years.** As a general result, the following particulars
flow from this portion of the examination : — In 27 persons, the
disease was within one month's duration ; in 40, from one to six
months; in 17, from six to twelve; 45 persons were affected from
one to five years ; 29 from five to ten ; and 34 over that period*
In the analysis of this column the duration is given from the ear
longest affected.

The hearing distance observed may be thus classified : — 70
could not hear the watch imder any circumstances ; 4 heard on
its being pressed against the auricle; 61, on merely touching that
part; 125, within six inches; 22, from that distance to three feet
and upwards; and in 18 the hearing distance was either normal
or unrecorded.

The auricle was healthy in 264 instances ; presented conge-
nital peculiarities in 10; and was diseased in 26.

Ihe state of the meaJlus and external andiiory canal may be thus
defined : — Normal in 68 ; dry and devoid of cerumen, with the
membrane whiter than natural, and slightly wrinkled, or pre-
senting towards its outward margin a few dry scales, — characte-
ristics of disease in the neighbouring structures and general accom-
paniments of deafness, — 78. It was coated with discharge, the
lining thickened, and frequently of a pink colour or vascular, or
the passage filled with crusts of inspissated mucus from previous
discharge, in 83 instances ; and of these cases, 18 had polypi grow-
ing from some portion of the canaL In 25 cases the passage was
filled with cerumen of different qualities and degrees of consis-
tence; these, however, form no proportion of the cases of deafness
arising fix>m simple impaction with cerumen which occurred dur^

136 AVALT8I8 OF BB0I8TBT.

ing the period when the foregoing 200 cases were recorded, Imt
are inserted in the Registry on account of other abnormal condi-
tions which presented, both as regards the pathological appear-
ance of the membrana tympani, or the middle ear, on the remo-
val of the offending body. In 26 cases the canal was inflamed;
in 9 its walls were so much thickened or approximated, as to
give the external auditory aperture the appearance of a mere
slit ; bony growths presented in 4 instances ; and a few cases oc-
curred of condylomata and other protuberances filling up the
meatus ; 4 cases of congenital peculiarities, as regards the length,
width, and tortuosity of this canal, also presented, as may be
learned by an examination of the cases in detail. In order to
economize space, much contraction was obliged to be used in the
terms employed for recording the state both of the external
meatus and the membrana tympani.

The state of the membrana tympam is the most yaluable result
afforded by the examination of these cases. In 10 instances only
was it found natural, so that such may fairly be stated as the pro-
portion of cases of *' nervous deafness."* In 176 it was thickened
and opaque, in whole or in part, from disease of its external layer,
owing to inflammations of various kinds — with and without otor-
rhoea, pressure, or ulceration — from deposits of lymph between its
laminae, or from thickening or vascularity of its mucous lining.
These opacities varied as much in shade as the same forms of
disease present in the cornea — &om a slight nebula to that of a
dense white leucoma ; and the analogy between the diseases of
these two structures, the cornea and membrana tympani, can only
be appreciated by those conversant with both. Sometimes it
presented a slight opalescence, or skimmed-milk hue ; at others,
a general dense opacity, and in these cases the membrane was
most firequently collapsed. In some cases the opacity presented
a mottled appearance, like that seen on the back of the cornea in
aquo-capsulitis ; in others it appeared like mother-of-pearl. The
most frequent site of isolated dense opacity was the inferior attach-
ment of the membrane, where it presented a crescentic white
band, about a line in breadth, and somewhat resembling the arcus
senilis. In a few instances a dense white line stretched between

8TATB OF THB MBMBBAVA TTMPANI. 137

the extremity of the malleus and some point of the circumference
of the membrane. Around the attachment of the malleus it was
frequently thickened and opaque. In many cases there was a
yellowish tint imparted to the membrane, which gave it some-
what the appearance of old or crumpled parchment.

In 13 cases there were connected with these various states of
opacity thin clear spots of membrane, about the size of mustard-
seeds, which, when air was pressed into the cavity, generally
bulged outwards into small pouches ; and this phenomenon oc-
curred even in instances in which the membrane as a whole did
not appear to be affected by the volume of air. It is not impro-
bable that these were the sites of ulcers in which the external
layer, or the internal mucous one, had been removed, and the
middle fibrous structure remaining unaffected was thus pressed
outwards into small hemise. Occasionally the whole surface of
the membrane was irregular.

The amount of polish was various : in many cases the surface
of the membrane resembled muffed glass ; in others, although
there was considerable opacity, the normal shining character was
preserved, and light reflected in the usual manner. It is possible
that in these latter cases the opacity may have been seated in the
mucous layer lining its inner surface.

There was facial paralysis in 4 instances.

In 4 cases there was a deposit of hard, gritty matter, between
the laminae of the membrane, of a yellowish colour, with a sharp,
defined edge, like the atheromatous substance formed between
the coats of arteries.

It is not, in the present condition of our knowledge, always
possible to state what was the precise form of inflammation or
other disease which produced the effects particularized in the
foregoing Registry, which merely records the appearance at the
moment, and the pathological results of previous disease.

In 121 cases the membrane was more or less vascular; some-
times it presented a uniform pinkish hue, deepening in colour
from that of a monthly rose-leaf to that of a bright blood-red or
scarlet, as when affected with recent inflammation. Occasionally
the redness was circumscribed, presenting a zone around the in-

188 AVALTns ov Bionnnr.

ferior attachment of the membrane, not unlike that aeen in
of corneitis ; in others, showing Bereral small dots, or brighten-
ing the site of the attachment of the malleus. In noting the oasca,
a distinction was made between tints of colour and yascularilj;
in the latter the red vessels were distinct and plainlj discemil^
Where the naturally-thickened membrane shelves off graduaUj
into the roof of the meatus is a very common locality for redness
and vascularity, even in otherwise healthy membranes. Where
distinct vessels could be traced, they were generally observable in
that position, or coursing from above downwards along the manu*
brium, or spreading from the point of that bone to the posterior
or inferior attachment of the membrane. In some instances the
whole surface was not only of a deep red, but also granulart
like that of a ripe raspberry, or the appearance so frequently
presented on the inside of the upper eyelid ; — such were cases of
long-continued otorrhcaa. Although this cameous condition was
often seen, and although so many cases of otorrhcsa and polypus
occurred, I have never observed a polypus growing from the
external surface of the membrana tympani, either in these 200
cases, or in the many hundred ears that I have examined. The
general red colour, as well as the distinct vascularity, was always
increased by any attempt made by the patient, whether successful
or not, to force air into the tympanal cavity. That blood is deci-
dedly pressed into the structures of the ear by a forced expiration,
or inflation after the manner described at page 64 I had very
recently an opportunity of determining. I removed a polypus at*
tached by a fine peduncle to the anterior wall of the meatus, near
the attachment of the membrana tympani ; nothing remained of
it but the bright-red spot from which the morbid structure grew.
After the haemorrhage ceased, and when the parts were brought
into the field of the speculum, I desired the patient to inflate
the drum, when I remarked that each time he did so, the blood
pumped out of the spot from which the polypus had been cut.

In 53 cases the membrana tympani was more or less collapsed,
a condition already referred to at page 14, and the cause of which
would, from the dissections of both Mr. Swan and Mr. Toynbee,
appear to be adhesions passing through the cavitas tympani,

8TATB OF THE CAYITAS TTHPANI. 139

either between the mucous surface of the membrane itself, or
the ossicula connecting it with the inner wall of that cavity, and
thereby limiting their and its motions. In the majority of these
instances, neither by natural nor artificial means could the vibra-
ting portion of the membrane be pressed outwards, although in
some of these cases there was positive proof, by catheterism and
the air-pump, that the Eustachian tubes were free. As might
naturally be expected where the membrane was drawn so much
inwards, either by the mechanical causes alluded to, or from pres*
sure of the external atmosphere where the Eustachian tubes were
not free, the malleus projected outwards, considerably beyond
the line of the membrane, which dipped from it, like a festoon,
on either side. The great bulk of these cases of collapsed mem«
brane also showed evidences of thickening and opacity. The
membrane was perforated in 48 cases, the size and position of the
aperture presenting great variety. In most, but not all of these^
the air passed through with a whistling, squeeling, bubbling, or
gurgling sound, — each peculiar tone being, no doubt, produced
by the size, position, and valvular character of the aperture, as
well as the fluids through which the stream of air passed, and
possibly also by the condition of the margin of the hole, which
was sometimes thickened, and frequently inverted. In 25, the
perforation existed inferiorly or anteriorly, opposite the opening
of the Eustachian tube ; in 10, posteriorly ; and in 13 the great
bulk of the membrane was removed ; and the remnant, with the
ossicles, was drawn upwards and backwards, while the cavity of
the tympanum, and the promontory in particular, was distinctly
visible, with its lining membrane red and villous. In 22 instances
the membrana tympani was, from obstructions in the canal, unseen.
The state of the middle ear and Eustachian tube is not so satis-
factorily recorded as that of either of the foregoing subjects, as it
is not possible to diagnose with accuracy the pathological condi-
tion of this unseen cavity. Where manifest disease showed in
the membrana tympani, or where that structure was open — with
muco-purulent matter pumping through it — it may be fairly sup-
posed that the fine mucous lining of the cavitas tympani could
not have been in a perfectly healthy condition. Where the aper-

140 AVALT8I8 OF BSGUTBT.

ture in the membrana tympani was sufficiently large to admit of
inspection of the parts beyond, their condition is generally stated
in the tenth column of the Registry. The cavity was exposed
in 28 ears ; in 89 there is no record of its state ; in 129 it was
inflatable, and in 73 uninflatable, — ^the mode of examination
being, in most instances, that described at page 64. In many
instances, particularly those in the latter portion of the Registry,
an exploration was made by means of the Eustachian catheter and
lur-prcss.

Pain. — The statement given on this point must, particularly
in cases of long standing, be received with caution. In 115 in-
stances the patients had experienced pain, either in one or both
ears, at some particular period of the disease. In 124 cases
they stated that they had never had pain ; and in 61, the notes
from which this Registry has been compiled make no statement
upon the subject.

Noise. — In 182 cases there was tinnitus; in 58, none; and in
60 there is no record. What I have already written upon the
subject, at page 82, may serve as an explanation for the summary
of this symptom.

The state ofthroai was normal in 181 cases out of the 200, a
fact which goes far to disprove all that has been written upon
what has been termed ** throat deafness ;'" but then it is only fair
to state, that enlarged tonsils are rare among the lower orders.

The disease teas attributed to cold, or variations of temperature,
by sitting opposite a broken window, or being exposed to a draft
of air in a railway-carriage, &c., in 63 cases; to scarlatina, in 14;
fever, 8 ; measles, 3 ; influenza, 3 ; scrofula, 4 ; syphilis, 2 ; and
bathing in the sea, 5 ; injury or accident, 11 ; occurred after partu-
rition, 3 ; followed erysipelas, 2 ; small-pox, 1 ; intemperance, 1 ;
and in the remainder, the patients were unable satisfactorily to
account for the accession of disease. It must, however, be borne
in mind that the persons from whom these accounts were received
belong to a class that pay but little attention to the early symp-
toms of deafness, and that in very many the disease approached
gradually and without warning. In children and young persons
the flrst symptoms of deafness are, unless accompanied by pain or

CLASSIFICATION OF AUBAL AFFECTIONS. 141

discharge, generally unattended to, or are attributed by the friends
to inattention or stupidity.

From the records of the foregoing 200 cases, taken indiscri-
minately as they presented at a public institution, as well as
Mr. Toynbee*8 dissections already detailed, it is incontrovertibly
manifest that inflammatory affections of some form or other have
been the chief cause of aural diseases. This conclusion must, I
think, be conceded ; and it is of vast importance that the Profes-
sion should be convinced on that point, as, on the one hand, it
shows not only the inapplicability of the various nostrums still in
use for '* deafness," while, on the other, it holds out a fair hope of
alleviating diseases of the ear, if taken in time, by the ordinary
means in use for arresting inflammation of the structures engaged.

That a large proportion of diseases of the ear depend upon
constitutional taint, and are of a strumous character, is well
known to most medical practitioners. In some of Mr. Toynbee's
dissections the diseases of which the patients died have been re-
corded. The deaths of 52 were attributed to diseases of the lungs,
of which 39 were from consumption. Epidemic diseases carried
off 24, of which 16 were by fever. In 18 the deaths were caused
by diseases of the brain or nervous system, and 15 died from dis-
eases of the digestive organs.

Those only who have been engaged in accurately recording
cases, and compiling statistics therefrom, can well understand or
appreciate the labour necessary to effect the objects intended.
In concluding this portion of my work I would earnestly entreat
those gentlemen connected with public institutions where diseases
of the ear are treated, to introduce some form of registry by which
a record may be preserved of the physical signs exhibited in cases
of deafness ; and occasionally to make known the results.

Having now, in accordance with the plan laid down for the
arrangement of this work, given some account of the principal
writings and discoveries connected with aural surgery ; having
entered fully into the best method of examination, in order that
an accurate diagnosis might be formed; and having also dis-
cussed the subject of the statistics of ear diseases, it only remains,
before I enter upon their description and treatment in detail.

142 CLA88IFICATIOV Of AU&AL AFFlOTIOVt.

to offer some Femarks upon the best nosological airangement of
these affections.

To the difficulties attending all synoptical arrangements^ we
have here to encounter additional ones, arising from the obscurity
of the parts affected : and, whether we attempt a classification ac-
cording to the symptoms, as the means employed by CuUen and
Mason 6ood,^-or base it upon the normal or morbid anatomy of
the tissues affected, as by our modem nosologists, the same diffi-
eulties beset us.

The earliest chart of aural diseases worth mentioning is that
arranged by Cralen. It consists of five affections, viz. : otalgia,
baruckaia^ kophotis^ parakauds^ and parakoutmata ; but these, it
is perfectly evident, were but symptoms, not diseases; and to
these he added, pain in the ear from cold, inflammation, and
*' ex flaJtaUnto spiriiu out craitiB H vUoom humaribus eat ex eerom
et aanums humoribuaJ^

The first attempt at an arranged nomenclature of aural dis-
eases in Great Britain was that by Buchanan in 1825, who, in his
^ Illustrations of Acoustic Surgery,^ endeavoured to classify those
affections according to the parts engaged ; but his diseases are
mere symptoms. It contains three orders, twelve genera, and
thirty-three varieties ; that, however, his division is most imper-
feet, nay, in some respects, absurd, may be learned by an exami-
tion of his fourth genus alone, styled, '* Impedimeniwn Externum^
or obstruction of the external meatus, under which he enume-
rates four species, each resulting from causes totally different, and
quite unconnected with one another, viz. : " Impedimentum Ex'
traneum^ from extraneous substances ; Impedimentum Induraiun^
from indurated wax ; Impedimentum Polt/posum^ from polypi ;
and Impedimentum Excrescens, from excrescences** ! I

At page 35 I alluded to Mr. Uarvey*s '* Synopsis of the Dis-
eases of the Human Ear,** published some years ago, and offered
an opinion as to its value and peculiarities. As a further ex-
ample, we find in Class II. (qucere III.)» Order i. Laburinthos— «
variety of diseases : — Inflammations, ulcerations, perforations, ex-
crescences, concretions, hydatids, effusions of blood, formations of
pus, &c., &c. affecting the labyrinth, and also the fluid of that

CLA88IFI0ATI0V OF AUAAL AVFBCXIOHS. 143

cayity, but expressed in high-sounding, Chreek-derived tenns, for
which, as special diseases, there is no warrant that I am aware of.
It is high time to get rid of such attempts, which merely mystify
the student, and serve to frighten the patient. If we want com-
plexity of nomenclature in diseases of the ear we had better apply
to the Chinese or the Hindus.*

The anatomical division into the external, middle, and inter-
nal ear, presents a natural basis for classification, and such was the
method adopted by Du Vemey. Deleau's Table is perhaps the
most artificial, and at the same time incomplete ; he gives five
classes, two of which are devoted to affections of the Eustachian
tube : the first is divided into two orders, for the alterations pro-
duced in its naso-guttural orifice by pharyngeal disease, one by
chronic inflammation, the other firom enlarged tonsils, — an idea
that has been much enlarged and improved upon in England,
although I have not yet heard of a single dissection showing that
an indurated tonsil in any way pressed upon or produced an alte-
ration in the trumpet-mouth of that canal. The second class con-
tains three orders, consisting of simple obstruction, chronic inflam-
mation, and stricture of the upper portion of the tube, not pro-
duced by disease in the pharynx, but all arranged to meet the
author's peculiar views with respect to Eustachian catheterism
and aural auscultation. His third class consists of inflammation
without secretion, and muculent accumulation in the cavity of the
tympanum ; the fourth includes inflammation and perforation of
the membrana tympani ; and the fifth is devoted to complications
attending diseases of the middle ear, the first and second orders of
which are simply combinations of the foregoing ; and the third
order includes diseases of the middle ear and labyrinth.

In the two first editions of his work on Diseases of the Ear,
Ejramer adopted the original division of Du Vemey, but mingled
the anatomical and pathological basis in the subdivision of the
diseases of these parts ; as for instance, erysipelatous and phleg-
monous inflammations, and also inflammations of the glandular,

* See Commentary on the Hindu System of Medicine, by T. A. Wise, M. D., Calcntta,
1S45, pi«e 2S7.

144 GLASSmOATIOV OF AUSAL AFFBOTIOHB.

cellular, and periosteal structures. In the last edition of his work
he adheres throughout to the anatomical basis, as, for instance, in-
flammation of the cuticle, the cutis, the cellular membrane, ma-
cous tissue, and periosteum, &c.

Mr. Wharton Jones's arrangement is entirely an anatomical
one, consisting of two parts, viz.: the diseases of the acceasoij
organs of the apparatus of hearing, — and the diseases of the fun-
damental organ of hearing, — the ear-bulb, or labyrinth, — with the
minute subdivisions of both these portions.

Mr. Williams does not attempt any classification whatever;
and Mr. Pilcher*s work is likewise defective in this respect, hb
arrangement being a simple enumeration of aural affections, di-
vided into— the abnormal conditions or malformaUons ; otitis, or
acute inflammation ; chronic diseases of the ear; and nervous dis-
eases of the ear.

Lincke is by far the best modem classifier: he makes three
divisions ; but he does not classify the diseases of the sentient
portion of the auditory apparatus, or those producing nervous
deafness. We hope to see a third volume from this author on these
obscure forms of disease. In the first division we find —

INFLAMMATIONS OF THE ORGANS OF HBABINO.

Sec I. — Simple. Seg.II. — Complicated and Specific

Outer Ear. — Attritus Auricu- Otitis, Erysipelatosa.

lae. „ Catarrhalis.

Erythema Auriculae. „ Gonorrhoica.

Inflamraatio Auriculae Phleg- „ Rheumatica.

monosa. „ Arthritica, s. Otagra.

Pernio Auriculae, a frigore. „ Scrophulosa.

Infiammatio Meatus Audi- „ Syphilitica.

torii. „ Morbillosa.

InflammatioMembranaTym- „ Scarlatinosa.

pani (Myringitis). „ Variolosa.

JdiddleEar. — Otitis Universalis „ Eczematica s.CrustaLac-

8. totalis interna. tea.

Infiammatio Tubae Eustachi- „ Herpetica.

anae (Syringitis).

CLASSIFICATION OF AURAL AFFECTIONS. 145

His second division includes —

AFFECTIONS CAUSED BY SOLUTIONS OF CONTINUITY.

Contusio Auriculae. Vulnera Totalis Auris.

Vulnera Auriculae. Coloboma Auriculae.

Fractura Auriculae. Foramina Membranae Tympani.
Vulnera Membrana Tympani.

The third division consists of —

AFFECTIONS CAUSED BY COHESION OF PARTS.

Dilatatio Meatus Auditorii. Strictura tubae Eustachii.

Strictura Meatus Auditorii. Obturatio tubae Eustachii.

Compressio s. Thlipsis Meatus CoUapsus tubae Eustachii.

Auditorii. Obliteratio tubae Eustachii.

CoUapsus Meatus Auditorii. Imperforatio tubae Eustachii.

Atresia s. Obliteratio Meatus Aneurisma et Varix Auriculae.

Auditorii. Cirsomyringa.*
Dilatatio tubae Eustachii.

I was indebted to this enumeration of Lincke's for the first ac-
count of some of the diseases I introduced into the original edition
of the accompanying Nosological Table.

In Part II. of my Contributions to Aural Surgery, published in
1844, 1 gave a Nosological Chart of Diseases of the Ear, " more for
the purpose of eliciting inquiry, and as a basis for future investi-
gations, than as possessing any great merit of its own." The ge-
neral principles upon which that arrangement was based I still
adhere to, viz. — the primary divisions into the diseases of the
auricle and external ear, with the mastoid and pre-auricular re-
gions— in fact, all the parts visible to the unassisted eye, or
which can be appreciated by the touch ; — those of the external
meatus and auditory canal ; the affections of the membrana tym-
pani ; those of the middle ear, or cavity of the tympanum ; the
morbid conditions of the Eustachian tube; and lastly, the dis-
eases of the internal ear, so far as they have been recorded by

* Handbnch der theoretischen and practischen Ohrenheilkunde, — von Dr. Carl Gnstav
Lincke. Zweiter Band. Die Noflologte and Therapie der Ohrenkrankheiten. Leipzig,
1840. Referred to at page 30.

M

146 CLASSIFICATION OF AURAL AFFBOTIOHS.

authors or have passed under my own observations. While,
liowever, this anatomical division serves as a basis for the orders,
and, to a certain degree, influences the division into genera, in
accordance with the structure affected, it is not possible, consis-
tently with the phenomena of disease, to carry it beyond that
point, and therefore the species and varieties of diseases and acci-
dents arc not confined to particular structures, but arc classified
according to their symptoms and the other peculiarities of the
affections themselves. As it is not possible to limit disease, espe-
cially of an inflammatory character, to any particular structure,
so is it impossible to carry the anatomical division beyond a cer-
tjiin extent.

In this classification I have inserted most of the congenital mal-
formations and a few rare diseases, upon the authority of credible
authors, but with these exceptions the rest have passed under my
own observation. I have also reduced the nomenclature as far as
possible to English. The chief alteration in the present arrange-
ment consists ol the position given to the various a&ections produc-
ing discharge from the meatus, and known under the terra Otor-
rhasa, which I have distributed according to the original locality
or structure affected; but owing to the great importance of this
symptom, its frequency in these countries, the variety of morbid
products, even in remote structures, which it may produce, and
the fatal results which sometimes attend it, I have devoted a sepa-
rate chapter to its consideration. The number of inflammations
which may give rise to, and the variety of structures from which,
discharges from the ear may proceed, either originally or by sub-
sequent extension, prove the impossibility of retaining the anato-
mical division beyond a certain point. There are some diseases
in the accompanying table which belong as much to one division
as another, for instance, those of the membrana tympani ; and
again, there are others, — at least such well-marked symptoms as
to have acquired the names, if not the importance, of disease, —
which it is diflicult to place, from our not perfectly understanding
where they have their seat, as otalgia and tinnitus aurium ; but
these are objections to which every synoptical arrangement must
be liable.

XOaOLOQICAL TABLB OP AUHAL DISEABBB.

DISEASES OF THE ACRICLR, AND THE AURICULAR RBGtOKS.

' Impeifacl or IrnsgnUr developmeiil.

Incised nounila.

Arwuffnotn or thk Suh.
C*arEii.

Aywtanotii of the Maktoi

Contused lio.

Fracture uF curtiliige.
( Fluttening uid obliteration uf h>'
( Slougbing and gangrene.

Keloid and fibrous,
liyiwrtropliy snd fatty depoiit.
PhlaginDncu.i— JilTu^eO am! clrcumMribiil.
TnKi{H'hiioii«_ai;utc and chronic.

Q uf maaloid pcrioalenm.

of mastoid gland.
'nn on mastoid process.

DISEASES OF THE EXTERNAL UBATUS.

r Meatus wanting in bone and curtiUgs.

COMOCMrTAI. HAI.POBMA7

DiMAMB or CBnuiuaous GuAims.

IxPLaMVATTOB.

i contracted or Coitnooa.

I closed hy (bIh mflmbrane.

1_ polvpom eicieecenoe in.

{Stt AUKICLE.)

Inereasa oT cennnen, cbrooic and ac
DtflcieDcy of cenimea.

All«tntions in qualit; of cerumen.

Exanlbetnalons; — Otorrtice*.

Gonorrhceal I'Otorrboea.

Petiaate«l ; — Ulorrhcaa and cari

148

K080L00ICAL TABLB OF AURAL DI8RA8SS.

DISEASES OF THE EXTERNAL MEATUS — continued.

Affbctions of thk Skix.

Morbid Growths, ani> Altkba-
TIONS Df Camai.

FiaruLA.

Caries.

Maxjonamt Dibkasb.

KczeiiiA and herpes.

Thickening and morbid growth of caticle.

Piligrowth.

Ulceration.

Collapse.

Stricture.

Dilatation.

Polypus and granulations.

Exostosis.

Morula and condylomata.

i

Osteosarcoma.
Cancer and fungus.

DISEASES OF THE MEMBRANA TYMPAHI.

CONOKNTTAL MaLFORMATIOIIS.

Wounds amd Imjurirs.

Imflammatiox

i Wanting.
Covered by false membrane.

j Rupture.

( Mechanical injury.

Acute, circumscribed ; — abscess.

diffused, Rheumatic.

Gouty.

Exanthematous ; — Otorrhcea.

Gonorrhoea! ; — Otorrbosa.

— of mucous layer ; — Otitis.

Subacute.

I

Syphilitic.
Strumous.
Typhoid.

pressure.
PerforaUon ; ) otorrhak

Chronic; granular; — pannus.

AxTBRATioxs IN CcrncuLAR Later. J Ef^J"* .*"**. °®'T*®'*

( Thickemng from pn

( Total destruction ; {

Opacitt akd Morbid Dbwwts «. \ ^^^ '^f'"' ^^ 'J''*'"'^ '^ ""*•• "'J*'-

( Atheruroatous and calcareous deposits.

Alterations of Positioh. i

Collapsed or flat, tympanum open.

Eustachian tube closed.

from adbesiooa in ^rmpviiim.

DISEASES OF THE CAVITAS TTMPANI.

Cohoenital Malfobxatiohs.
Woukds and Injitribs.

H^DfORRHAOK.

Cavity wanting; — (osseous).

filled with morbid deposit.

Ossicula wanting, irregular, or misplaced.
Fenestns wanting.

From fracture, or penetratiiig inftrament

BOBOLOQICAL TABLE OV AURAL DISEASES.
DI8KA8B8 OF THE CAVITAB TYMPASI — continued.

JnrUMMAIto*.

SuImcuU, CaUrrhil.

Cbniriic, with thickening of tbe roemhrmne, —

raemiirana tymiuini perf^K^t

tha caTityvxp)^ from perfbntion

M dMtrnction -of mcnibranii tymptni.
Periosteal ;~Otitis, OtoirtusH, diwan of brain.
Ofmuloidcijli.

PolypoB and granutitlona.

' 0»lBcalion«fl'en<
Oiteuisrconia, jiiirl
Fungus JiwniBlode).
Ancbyloiis.
Di-placemeut.
Lou or.

DISEASES OF THE KDBTACHIAN TUBE.

FoRKtoa Bouim n

COKOBHITAL HALPOKUATIOHa.

{CatarHiaL
Chronic, witli thlckeniDg of i
Syphilitic ; — ulcerati fb.
I thidfflncd and lelaxed

WoLMOa Ana Ihjubibb.
IxnjkMUAnoii.

Uauo!(a:<t GROwTHa.
TuntiTui AuBiim.
Otalcia.
Kbhvovi DzaraEss,

DISEASES OF THE LABYRISTIT

l^yrintli wanting, irregular, or imperCsctly do-

velnped in name of lb parts.
filled with caMoui matur.

Auditory nerve wanting or atrophied.
Fracture, with »eronB or bloody effuaion.

Irron

Olitii \ — Otortlicca ; — cerebral disesic

J Wlfl cxaltflliijn ofiieari
} Without cxultatiiiQ of ht

J From cerebral diwase.
diaeaaeofmoditor}

DEAF-DUMBNESS.

( From k

i — di

150

CHAPTER IV.

DI8BA8BS OF THB AURICLE, MASTOID REGION, AND BXTERNAI.

MEATUS.

AoAtomj of the Aaricnlar Region : the Aniide and External Aaditoiy CanaL — Congenital
Malformations and Diseaaes of the External Ear ; Irregular or imperfect Derdop-

ment — Wounds and Injuries of the Auricle.— Alterations in form Morbid Growtha.

Inflammations. — Gout. — Cutaneous Affections : Eczema, Herpes, and Pemphigaa. —
Cancer. — Affections of Mastoid and Auricular Regions. — Post-aural Tumours. — Dis-
ease of Mastoid Gland. — Inflammation of Periosteum. — Chronic Abscess. — Aneurism.
— Caries — Cerebral Otorrhcea. — Injuries of External Meatus : Foreign Bodies in. —
Diseases of Cerumenous Glands — inflammations : Acute, Chronic, and Specific. — Ex-
ternal Otorrhoea. — Fistula and Caries. — Cutaneous Diseases ; Piligrowth. — Morbid
Growths. — Polypus, Exostosis. — Alterations in form of Canal Malignant Diseaaea.

TT IS not my intention to enter minutely or at any length upon
■^ the subject of the anatomy of the organ of hearing, but sim-
ply, to preface the description of the diseases of each particular
part with a brief sketch of the structures which those diseases
engage, in order to revive in the memory of the reader some ge-
neral knowledge of the parts under consideration.

An ear consists of two portions, a sensitive and a mechanical;
the latter being generally subservient to the former, and modi6ed
according to the peculiar habits, exigencies, and mode of life of
the different classes of animals: in fishes, cetacea, and amphibians,
to inhabit the water; in birds and insects, to progress through the
air; in moles, to burrow and seek their food under the ground;
and in man and other terrestrial animals, to walk on the earth.

The human ears are situated in the temporal bones, one on
each side of the cranium. Each temporal bone consists of three
parts, — the superior, thin, squamous, or scale-like portion, which
overlaps the frontal and parietal bones upon the temporal region,
but which is seldom engaged in aural diseases; the mastoid,
or posterior inferior part, thick and rough for the attachment of
muscles, and hollowed into cells, which communicate with the
cavity of the tympanum, for the purpose of increasing the surface

▲NATOMT OF THE EXTKRNAL BAR. 151

on which sound acts; and the petrous portion, so named from its
stony hardness, which passes inwards from the junction of the
two former to form a part of the lower arch or base of tlie skull;
besides various processes, the chief of which are the zygomatic
and the styloid. In the petrous portion is placed the special or-
gan of hearing. Anatomists have divided the ear into thiee
parts: the internal, or labyrinth, containing the expansion of the
auditory nerve, and including the cochlea, vestibule, and semi-
circular canals; the middle, or cavitas tympani, enclosing the
chain of ossicles, bounded externally by the membrana tympani,
and internally by the outer wall of the labyrinth, communicating
posteriorly with the mastoid cells, and having an inferior exit
through the Eustachian tube; and the external ear, consisting of
the meatus auditorius extern us, and the pinna or auricle.

Viewed externally, the parts which become concerned in dis-
eases of the ear, and which may be styled the aural region, are
contained within that space between the malar bone in front, and
the edge of the occipital behind, bounded above by the attach-
ment of the temporal muscle, and below by a line drawn from
the angle of the jaw to the lower margin of the mastoid process.
In the centre of this lateral space of the head is placed the auricle^
a cartilaginous projection, varying in size, shape, and angle of
attachment in different races of men, as well as in different indivi-
duals ; and in the lower animals presenting all those modifications
applicable to their respective circumstances and habits of life,
with which every one is familiar. The human ear is an irregu-
larly-curved plate, with its concavity directed forwards and out-
wards. It consists of the outer fold or hem turned over on itself,
and called the helix, broad and deep in front, where it rises
from the upper boundary of the external meatus, and gradually
becoming narrow, thin, and fleshy, as it is lost in the lobe be-
hind and below. Its size, shape, and amount of overlapping
varies considerably in different individuals, and in many persons
this fold is altogether wanting, particularly posteriorly ; we also
frequently find in it small hard nodules. Within the helix is
another elevation, denominated the anti-helix, of a somewhat
triangular shape, arising in front by two roots from behind the

152 ANATOMY Of THS AURICLS.

anterior curvature of the helix. Curving upon itself, it forms the
superior and posterior boundary of the concha, and ends in the
anti-tragus, a nipple-like projection from which the lobe depends.
Between the eminences of the helix and anti-helix runs a deep
groove, called the navicular fossa; while the space between the
roots of the anti-helix is — after the usual fashion of the old anato-
mists, when they had exhausted their various similitudes — called
the fossa innominata. In front of the external auditory aperture,
which it partially overlaps, and arising below the roots of the
zygomatic process, is a concave triangular projection, called the
tragus, on account of a tuft of hair resembling a goat^s beard,
which in some persons, particularly in advanced life, grows from
its tip. From the base of the tragus being in immediate conti-
guity with the temporo-maxillary articulation, it is moved by the
action of the jaw, particularly in eating. The cellular and adipose
substance in front of its anterior edge is often the seat of inflam-
mation, and hence arises the pain experienced in such cases from
any motion of the lower jaw ; and the temporal artery passing
through this space, and there giving off the anterior auricular,
may account for the unusual amount of throbbing felt in abscess of
this region. The largest concavity is the concha, which, leading
into the meatus in front, forms posteriorly the hollow of the ex-
ternal ear, and is bounded above by the roots of the helix and
anti-helix, behind by the concave margin of the latter, and below
by the anti-tragus and a gutter- like fossa, which passes down-
wards somewhat in front of the lobe. The concha is generally
capacious enough to contain the top of the thumb. All these
eminences and depressions, as well as the posterior, inferior, and a
part of the anterior margin of the meatus, are fashioned out of
one continuous cartilage, which may be denominated the skeleton
of the car. Pendant from the lower edge of this cartilage is the
lobe, a fleshy projection, more or less long and thick in difierent
individuals, and passing ofi* anteriorly into the integuments of the
cheek beneath the tragus. It contains a quantity of cellular and
some adipose tissue, and is very extensile, as may be seen in in-
flammations, dropsy, and emphysema, &c. From time immemo-
rial, and among all nations, this part has been adorned.

ANATOMY OF THE AURICLE. 153

The caTtilaginous portion of the ear is invested with a strong
perichondrium, and the whole is covered with an envelope of fine
integument, highly vascular and sensitive, so as to be even sus-
ceptible of blushing and other peculiar impressions consequent
upon mental emotion. It contains many sebaceous follicles, par-
ticularly in the concha, where they sometimes become enlarged,
and present those dark worm-like bodies with which every one is
familiar. In some adults the auricle has a thick, leathery feel,
and it is often, even in the normal state, of a bluish purple colour.
Even in some new-born children we observe hair growing from
the upper margin of the helix, and in several hirsute males in mid-
dle life this is a common place for tufts of hair to project from,
as well as from the anterior surface of the lobe, the tragus, and
the anti-tragus. The hairs growing from these parts and around
and within the external meatus, though short, are generally very
stiff, like the eyebrows of some aged persons, and often become a
Bource of annoyance either by being entangled with the cerumen,
or by falling inwards, and irritating the membrana tympani.

The auricle is attached by ligaments, muscles, and the com-
mon integuments, to the skull, and by dense ligamen to-cellular
membrane to the anterior, inferior, and posterior margin of the
meatus, extending from the root of the zygoma to the mastoid
process. Among civilized nations this part is not so well deve-
loped, does not stand out at the same angle from the head, and
its muscular apparatus is not so much called into action as in
savage people, whose means of safety or subsistence depend to
a certain extent on their powers of hearing. Any one who ob-
serves the ears of a greyhound when that animal's attention is
specially engaged may form some idea of the beautiful muscular
apparatus which an ear in its natural condition possesses. Still,
we often meet persons who have the power of moving the exter-
nal ear in different directions, principally upwards, backwards,
and a little forwards.

Two sets of muscles have been described as belonging to the
human ear, but in the great majority of individuals they are
either rudimentary or are altogether wanting. The first, or the
extrinsic, are those which, attached to the head, move the exter-

154 ANATOMY OP THB MASTOID RBGIOV.

nal ear as a whole ; the second, or the intrinsic muscles, arising
from particular portions of the cartilage, and inserted into other
parts of the same structure, serve to increase its various concavi-
ties, and doubtless, when well developed, they assist to render the
external car at particular times a better collector and conductor
of sound. Besides these muscles, certain fissures, described by
Santorini, traverse the base of the cartilage near its attachment,
particularly where it forms the anterior triangular wall of the
flexible portions of the meatus, — which are supposed to contain
muscular fibres, capable of shortening that passage. It is said
that the tyrant Dionysius had a subterranean chamber constructed
in the shape of the human ear, which was in connexion with an
adjoining prison, and which he employed for the purpose of trans-
mitting whatever was said by those confined therein.

The size and form of the external ear have been justly consi-
dered characteristic of beauty and breeding; and the national pe-
culiarities of this feature are not unworthy of attention, as also its
figure and position in some of the bygone races. Those familiar
with ancient sculpture and painting, particularly among the
Oriental monuments, must have observed many varieties of it
It has been stated that in the ancient inhabitants of Egypt the
ear was placcid unusually high ; I have examined a great number
and variety of the crania of that people, and I have not found
the external meatus misplaced; but in the paintings and statues
the auricle appears to be prolonged upwards. This peculiarity is
more noticeable among the Asiatic races, strangers, slaves, and
captives, than in the true natives of the land, as may be seen from
Rosellini's faithful illustrations of the ancient Egyptian paintings.
My late esteemed friend, the talented S. G. Morton, of Philadel-
phia, has given some notices of the external ear in his valuable
ethnological writings.

The mastoid region may be defined as all that semilunar
space, for the most part uncovered by hair, behind and partially
overlapped by the auricle. Beneath the delicate skin of this part
we often meet one, sometimes two, small glands lying parallel
with the posterior attachment of the auricle; there is then a
strong fascia covering the tendinous expansion of the stemo-

ANATOMY OF THE EXTERNAL MEATUS. 155

mastoid muscle, and finally the periosteum. The posterior-auri-
cular branch of the occipital artery runs close to the junction of
the auricle and scalp, and its position should be borne in mind in
making incisions in this spot.

The meatu8 auditorius extemus exhibits greater variety in
length, shape, and direction than works on anatomy would lead
us to believe. It is an irregularly curved tortuous tube, wider
at the extremities than near the middle — from an inch and a
quarter to an inch and a half in length — ovoid in caliber exter-
nally, but becoming circular towards its distal end : and leading
from the concha externally, at first a little forwards and upwards,
then backwards and inwards, and again turning downwards, for-
wards, and inwards, to the membrana tympani, which separates it
from the middle ear. Owing to the oblique position of this mem-
brane, the depth or curvature of the glenoid cavity, and also from
the cartilage beneath being more complete, and prolonged infe-
riorly, the roof of the external meatus is somewhat shorter than
its floor. It is only by constant inspection, and also examining
a number of casts of this passage, that we can understand its
bearings and different curves. Independent of the oblique posi-
tion from above downwards of the membrana tympani, there is a
very well-marked obliquity presented by the tympanal end of the
bony meatus, which spreads forwards and downwards behind the
glenoid cavity, where the bone is remarkably thin, and sometimes
perforated with small apertures. It is difficult to bring this por-
tion into view in the living state, but it is frequently the seat of
polypus, which, when of a small size, often lies concealed therein,
and keeps up discharge long after the rest of the canal has as-
sumed a healthy character. It is best seen from within by making
a section of the bone behind the groove for the attachment of the
membrana tympani. The bony meatus is about three-quarters of
an inch in length ; its outer margin, particularly below, from the
root of the zygoma to th^ mastoid process, is rough for the at-
tachment of the auricle, which is fixed to it by strong fibro-liga-
mentous material. The external third or more of the meatus
auditorius externus is formed partly of cartilage and partly of
fibro-cellular tissue, and it is this portion alone which is capable

156 AHATOMT or THB KXTBRVAL MBATVl.

of dilatation even to a slight extent, but being suiceptible of (
siderable motion, it can be so far straightened as to permit a di-
rect stream of light to pass in through the immovable bonj
portion to the membrana tympani. The anterior outer wall of
the external meatus, formed by a triangular portion of cartilage
within and below the tragus, is influenced by the action of the
condyle of the jaw, as may be perceived by placing the point of
the finger within the meatus, and then opening and shutting the
mouth. In cases of inflammation of the passage, the motion of
the jaw, as also sneezing or coughing, causes on this account great
pain and distress. The parotid gland also coming up thus far, and
surrounding the lower and part of the anterior wall of the meatus,
causes, when inflamed, pain in the ear and deafness. The perios-
teum and perichondrium — the former of which is remarkably de-
licate— are covered by a reflection of the cutis from the auricle,
which is remarkably fine and vascular where it lines the osseous
portion, and its cuticular layer is reflected over the external
surface of the membrana tympani. This cuticular lining is sus-
ceptible of considerable thickening either by pressure or inflam-
mation, often presenting a macerated appearance : and in the dead
subject it can sometimes be drawn out entire, like the finger of
a glove.

Within the external margin of the passage, and in some per-
sons as far in as the junction of the osseous meatus, there are a
number of fine hairs, styled vibrissas, which, all pointing towards
the centre of the canal, serve to exclude insects or extraneous bo-
dies, but which, in cases of impaction of the canal with wax, act
like so many nails to retain the offending plug in situ.

Imbedded in the integument of the meatus, chiefly in the
membranous portion, and most abundant posteriorly, we find the
cerumenous glands of Wharton ; as a whole resembling a ring with
the setting behind, — each gland being somewhat the shape of
a Florence oil-flask. These secrete the substance so well known
as cerumen or ear-wax, of a brownish yellow colour, adhesive,
bitter, igni table, composed of a peculiar animal matter resem-
bling wax, lactate of potash, and some lime. There can, I think,
be little doubt that the ear-wax exercises some useful influeiiee

MALFORMATIONS 09 THE BXTEBKAL BAR. 157

in perfecting the external auditory passage as an acoustic instru-
ment, as well as serving to exclude insects. It is frequently
deficient, or altogether wanting, in cases of long-continued deaf-
ness, so that it is generally believed to be one of the causes of de-
fective hearing, and various nostrums are still in use for promoting
its secretion. I believe that the true cause of its deficiency con-
sists in inflammation of the glands from which it is secreted, or
of the structures in which they are placed. I have examined
numbers of the congenitally deaf and dumb, in whom the secre*
tion was quite abundant; and I have even seen it accumulate in
these persons, and produce such uneasiness as to require removal.

MALFORMATIONS OF THE EXTERNAL EAR.

The temporal bone as a whole is never, that I have heard of,
wanting, but great variety exists with regard to its different parts,
each of which presents congenital abnormities, which shall be
considered in detail. The external contour, particularly of the
squamous portion, is very variable, and seems to assume a special
or fixed character in different races of mankind. There is in the
College of Surgeons in Dublin the deformed skull of a boy aged 16,
who, I understand, died in one of our prisons while under sentence
of transportation, in which the left side is quite flat, and there is
no trace of squamous suture. Upon examining the cranium one
cannot help asking, — Would not that poor boy have been a more
suitable inmate for a lunatic asylum than a convict prison?

The auricle is not fully developed until the sixth month, and
is that portion of the auditory apparatus most liable to variety
and irregularity. Its peculiarities are sometimes so very slight
that those only who are in the habit of examining ears daily can
perceive any difference from the normal condition of this portion.
The size and shape of the whole auricle is very various in diffe-
rent families and individuals. The helix is, as already stated,
often wanting ; the lobe still more frequently. The concha, in-
stead of being a concavity, is sometimes a convexity. The auricle
is sometimes represented by a mere fold of skin ; I saw such a
case in consultation with Dr. Forrest some years ago ; it occurred
in an infant, and only existed on one side. Instances have been

158 MALFORMATIOKS OF THB SXTBRHAL SAB.

recorded of the total absence of the auricle, yet it is said the per-
sons heard well. Schmalz, in his Beitrdge zur Gehor und SproA"
Heilkuudej 1846, has 6gured three cases of congenital deformity
of the auricle, in the most remarkable of which there was no ex-
ternal meatus, and the upper portion of the helix alone was nor-
mal. This part has also been found cleft A plurality of auricles
has been remarked. Cassebohm relates the case of a child with
four ears, two naturally placed, and two lower down on the neck;
there were in that instance two petrous portions to each temporal
bone. Four auricles are not uncommon among some of the lower
animals, swine in particular : the old Irish pig, with long legs,
high back, and narrow snout, had very frequently supernumerary
auricles, small and misshapen, situated low down on the neck.
Sheep have sometimes four ears. Professor A. Thompson has
given a '* notice of several cases of malformation of the external
ear," in the Edinburgh Monthly Journal, but his description is
rather unsatisfactory, inasmuch as in the first case, that of W. B^
the peculiar malformation of the auricle is not specified; in the
second case, that of a young lady at Falkirk, she, he states, pre-
sented ** the same kind of malformation to a greater extent than in
W. B. ; and along with the local malformation of the ear, consider-
able imperfection in the lower part of the face;** and in the third
case, that of Miss R., ^* the form of the imperfectly developed
auricles, and the shape of the countenance, presented a remark-
able similarity to those of the girl at Falkirk." — See Numbers for
December, 1846, and April, 1847.

The same essay contains some remarks upon the causes of
muteism, which I cannot refrain from adverting to here. " The
instances," he says, " are extremely rare, however, in which deaf-
dumbness is caused by congenital malformation of any kind, and
it is sufficiently well known to all those who have been connected
with institutions for the deaf and dumb, that in by far the greater
number of instances of deafness, either total or to such a degree
as to induce dumbness, the affection has proceeded from diseases
in early life, such as scarlet fever, measles, and small-pox; the
inflammatory and suppurative process affecting first the cavity of
the tympanum, and being subsequently communicated to some

MALFORMATIONS OF THE EXTERNAL EAR. 159

part of the labyrinth." Surely the Professor cannot have exa-
mined any of the works treating of muteism, or he would have
been aware of tlie well-established fact, that in every country in
which the subject has been carefully examined, and faithful statis-
tics collected, the number of the acquired cases of deaf-dumbness
is about one-eighth of the whole. A case has been related in which
the auricle consisted in a fold of integument perforated with two
apertures, and with the concavity turned towards the head. The
auricle is sometimes the seat of congenital naevus, either alone or
in connexion with the same disease in the neighbouring parts. In
1810 the late Professor CoUes tied the posterior auris for aneu-
risqi by anastomosis of the auricle.

Congenital malformations and abnormal peculiarities of the
external meatus and auditory canal are by no means uncommon;
the passage is frequently smaller, and often more tortuous than
natural, and it has been found closed with a polypous excrescence
at birth. There is great variety in the length, caliber, and cur-
vatures of the sides of the external auditory passage among diffe-
rent persons, — perhaps just as much as there is in the shape of
the nose, the auricle, or any other feature of the face. I had no
idea how much diversity existed in the auricle until I began to
study diseases of the ear ; and latterly I have so frequently ob-
served congenital peculiarities and malformations of the auricle
in persons who have applied for advice on account of some aural
disease, that I have been forced to the conclusion, either that
these peculiarities occur much more freciuently than is supposed,
or that, in some way which is at present unaccountable, persons
possessing such peculiarities are more subject to aural diseases
than the rest of the community.

I have met with cases, both in children and adults, in which
the external auditory canal would not admit anything larger
than the end of an ordinary dressing-probe. I have also seen an
hour-glass contraction in the centre of the passage, which,
although it had never impaired the hearing, was yet a consider-
able impediment to the removal of some hardened wax which
bad accumulated behind it. The external meatus is sometimes
pretematurally wide. The meatus has been found double ; the

160 INFLAMMATIONS OP THE EXTERNAL MEATUS.

siipemumeraiy canal opening behind the auricle. False mem-
brancs stretching across the meatus have been recorded by many
observers ; and such cases are susceptible of relief by surgical ope-
ration, although considerable difficulty is always experienced in
keeping open the newly-formed aperture. Several cases have
been noted of imperforate meatus with and without any abnor-
mal condition of the auricular cartilage. Sometimes the place of
the external aperture is merely marked by a slight depression in
the skin, at others the membranous portion of the canal is perfect,
but beyond that all is solid bone. I have met with three ^ck
cases : one was a boy six years of age, labouring under otorrhcea
on the left side; upon the right the membranous portion of the
canal was perfect, but the osseous part was closed by firm bone,
covered by a thin layer of integument. The second was in a
woman, aged 30, born deaf and dumb; there was no osseous canal
on either side. The third case was as follows: —

A female, aged 20, applied at the hospital on account of otor«
rhcea of the left side. On examination, I found the right auricle
normal, but the meatus ended in a shallow cul de sac, lined by
smooth, white membrane, which just admitted the end of the little
finger. She was completely deaf on that side, but, strange to say,
until she had the inflammation and otorrhoea of the other, she
was quite unconscious of her imperfection. How frequently do
we meet with instances of total blindness of one eye, evidently
congenital, discovered by the merest accident long after birth.
Although the bottom of the shallow cavity in this case felt and
sounded solid, I determined upon exploring it, and made upon two
occasions a crucial incision ; but all behind the membrane, which
appeared to be a thin layer of cartilage covered with fine int^[a-
ment, was perfectly solid.

WOUNDS AND INJURIES OF THE AURICLE.

These injuries, either from accident or design, are not as fire-
quent in this country, nor indeed any other, as in former days.
** Cropping the ears** was, in the time of the civil wars, not an
unusual punishment, and it is still resorted to in some Elasteni
countries. I remember a baker in Cairo being nailed by the ear

INJURIES OF AURICLE. 161

to his own door for selling bread beneath the standard weight.
The punishment was a very severe one, as the man's toes scarcely
touched the ground. I suppose ^* nailing the ear to the pump"*
was, from the popular adage, a common form of punishment in
other days. Splitting or cutting off the ears was a cruel mode of
maiming and ill-treatment resorted to by the insurgents in this
country formerly ; yet we read in history of celebrated generals
forwarding to their sovereigns the ears of the vanquished, as tro-
phies of conquest. Having had an opportunity of examining
many of the wounded French soldiers after the battle of Constan-
tina, I was struck with the number of sword-gashes about the
head and face, and of the auricle in particular. I was informed
they were inflicted by the yataghan, the mode of using which,
somewhat after the fashion of carving a round of beef, may ex-
plain the way in which these wounds were inflicted. In Germany,
when sword duels were common among the students, surgeons
had considerable practice in simple incused wounds of the ear.
Instances have been related of adhesion having taken place even
after the part had been completely removed. Writers seem to be
averse to the employment of sutures, but we have not in these
kingdoms much experience of the matter. The application of
Imt, spread with white of egg, so as to keep the parts in strict
apposition, I have seen used with advantage. A cork pad, accu-
rately adjusted to the space between the posterior surface of the
auricle and the mastoid region, has been recommended, but the
ingenuity of the surgeon will, I think, without adhering to any
definite rules, generally enable him in every case to adapt the
means to the end. I have seen the auricle lacerated and contused
by pressure against a wall, by falls, and by the transit of a cart-
wheel ; and in the days of faction fights in Ireland, I have dressed
many dozen auricles split and bruised by blackthorn sticks, and
have often wondered at the small amount of injury or deformity
which follows such injuries. Fracture of the cartilage has taken
place from suddenly and violently doubling up the ear.

The operation of piercing the lobe for the introduction of ear-
rings, either as a sanitary measure, or for ornament, so common
among all nations, is not always unattended with unpleasant con-

N

162 nijuRiss OF AimicLB.

sequences. I have seen it give rise to erysipelatous inflammation,
to eczematous eruptions spreading over the side of the face, and
also to abnormal growths in the lobe. Piercing is usually per-
formed with a sharp awl pressed through, against a cork held at
the back of the lobe, by the jewellers, and those who dispose of
the wares, ornamental or medicinal, to be inserted therein.

The skin of the auricle is, as already stated, highly sensitiTe.
People speak of " blushing to the ears," because that part be-
comes red and hot upon mental emotion. Besides this, there are
many popular adages relating to this part. We have all felt one
or both ears unaccountably hot, and apparently swollen at par-
ticular times. If the left ear is red, it is said ** somebody is
speaking well of you,"* but if the right, the contrary. When, ac-
cording to the Mosaic law, a bondsman's term of servitude had
expired, and that from affection to his master he desired to remain,
the owner was directed to ** take an awl and thrust it through his
ear unto the door : and he shall be thy servant for ever" — Deut. xv.
ver. 17 ; — and my friend, Dr. Carter, has informed me, that when-
ever a negro in the West Indies wishes to attach to himself a dog,
he nails his ear for a day to the door-post of his cabin. The
state of the auricle is said to be characteristic of disease in other
organs : it is red in congestion of the head ; livid in diseases of the
circulating system ; and cold, thin, and insensible in nervous deaf-
ness, or in diseases of the internal ear. Pulling children's ears is,
I have no doubt, conducive to inflammatory affections, both in the
auricle and meatus. Boys increase the angle of the auricle, and
give themselves what are called " dog's ears," by pulling down
their hats or caps; and, on the other hand, old women, from
having tied up the auricle for many years, have so squeezed and
flattened this part, that it lies close to the head, and the various
curvatures, particularly of the helix, are obliterated. Sloughing
and gangrene may ensue from long-continued pressure during lin-
gering illness, or from exposure and want of due circulation, as in
fever, when the extremities at times mortify.

Baron Larrey's work, alluded to at page 48, contains some
valuable observations upon wounds of the auricle, and the mode
of treating them. Among other matters he mentions a case worthy

TUMOURS OF THE AUHICLE. 163

of consideration in a medico-legal point of view. An officer of
the French army stated that he was attacked by a stranger, who
cut off his ear, but Larrey, on examining the wound, discovered
that it had been done by the teeth. He also mentions the case
of a soldier, whose meatus had been grazed by a musket-ball,
and the parts adhering subsequently, the external aperture was
thus hermetically closed by the cicatrix. As the man's hearing
remained perfect, this case attracted great attention, and he was
introduced at one of the meetings of the Philomathic Society, in
the winter of 1815-16, as a singular instance of the preservation of
hearing after he had " lost, according to his own statement, several
small pieces of the meatus itself, besides all the small bones of the
ear P No doubt a French soldier is a very intelligent person, but
whether his word should have been taken by the Savans with re-
spect to the loss of the ossicula auditus is questionable ; and whe-
ther the Baron should have published the case as a ** surprising
circumstance,** without having made some attempt to explore the
state of the membrana tympani by dividing the external cicatrix,
is still more so. I mention the case, however, in order to show
the looseness which prevailed among medical writers, even of the
first eminence, with respect to diseases of the ear, twenty years ago.

TUMOURS OF THE AURICLE.

Morbid growHia of the auricle are by no means uncommon :
steatomatous and sebaceous bodies form in the concha ; I have
three times removed firm, encysted tumours, each the size of a
hazel nut, from the posterior end of the helix. Hypertrophy of
the lobe has proceeded to such an extent as to reach to the neck.
Boyer, in his Treatise on Surgical Diseases, has related the case
of a large pendulous lobe of that description, which he removed.
The following case of fibrous tumour of the lobe, No. 19 in the
Registry, is a good example of its kind.

M. S., a female, aged 19, has a hard, firm, ovoid tumour, oc-
cupying the centre of the lobe on each side, but largest on the
left — of which the accompanying woodcuts afford faithful repre-
sentations. It is of a stony hardness, and is quite distinct both
from the cartilage above and the fleshy part of the lobe, which it
appears to pass through. The skin covering it is smooth, and of

n2

1 paler M

164 TDMODBS OF THE ADBICLR.

a light pinkish hue, like that of a keloid tumour. It grew gra-
dually from the orifice made for holding the ear-ring, and haa been
several months attuning its present
size. The tumour upon the opposite j» ^
side, which also surrounds the hole / .jd
made for the ear-rin|!. is much f
in colour, and not larger than a
don pea. The girl states, that she ex-
perienced a great deal of pain and
Borcnesi in the wounds made in pierc-
ing her ears, and that about three or
four months afterwards she was ob-
liged to remove the ear-rings on ac-
count of thu irritation they produced.
The largo tumour was dissected out,
and the elliptical aperture left in the
lobe brought together with sutures. It healed kindly, and the
disoosc did not retuin. This second cut shows the shape of (he
tumour in profile. A section of the tumour
exhibited a dense yellowish- white fibrous ap-
pearance, and was ao hard that the nail made
little impression upon it. I saw this patient
about six months afterwards, and as the ex-
crescence in the lobe on the right side had not i
increased, she was nnwillin<; to have it inter-
fered with. Mr. Williams, in his Treatise c
the Kar, relates a case of tumour of the lobe which was removed
by Professor Syme, and which, from the description, would appear
to be very similar to that which I have described.

If tumours of this description wore frequently to follow the ir»
ritaiion caused by piercing the ears, we should find them much
more common, particularly among those nations who wear very
large, heavy, pendulous ornaments there ; but I have frequently
seen the hole made to hold the ear-ring elon<;ated to a slit three-
quarters of an inch long in some of the African and Oriental
tribes. The South Sea Islanders introduce pieces of wood, shells,
and other large Eubstancos, into apertures made in the lobes.

ivs tne snape oi tne

TUHOUBS OF THE AURICLE. 165

In a case of goitre, where the tumour extended over the side
of the neck, along the course of the mastoid muscle, which 1 re-
member seeing in the west of Ireland aome years ago, the lower
portion of the auricle was enlarged to the size of the palm of the
hand ; and we read that pendulous tumours, growing from the
external ear, are not unfrequent in those parla of India where
goitre prevails. Dr. Graves has published a case of fatty deposit
in the lobes ;-7 the patient died subsequently, and Dr. O'Ferrall
found, upon dissection, a fatty degeneration of the liver, and fatty
deposits in other portions of the body.

J. E., a male, aged 24 (No. 18 in Registry"), A tumour, about
the size of a small pear, occupies the upper portion of the lefb
auricle, between the helix and the concha. It is immovable, has
a tense, clastic feel, like that of a hydrocele, and the skin cover-
ing it is smooth, and of a dusky red colour. The whole auricle
is very hot, but the pain is not great. It is of three months' du-
ration, and baa been several times lanced by a medical man, and
a quantity of glairy matter discharged ; but as soon as the wound
healed the fiuid re-accumulated. Hearing unimpaired. The case
when admitted presented the characters shown in the accompany-
ing illustration.

A free incision was made through
the entire length of the tumour, and
about two ounces of glairy tenacious
fluid, of a yellow colour, like that
contained in a ranula or an enlarged
bursa, but mixed with portions of
flocculent matter, was discharged.
The sac was found to be smooth and
polished. The wound was dressed
from the bottom, with dossils of lint,
and a cold lotion was applied to the
auricle. Under this plan of treat-
ment the fluid did not again accu-
mulate, but the auricle presented

a hard, thickened, nodulated feel and appearance, which remained
for months, and completely eflaccd the natural curvatures and si-

166 INFLAMMATIONS OF THE AURICLE.

nuosities of that portion of the external ear. While the patient
remained in attendance at the Institution, he took Plummer^s pill
and bark, and had the thickened auricle painted over with tinc-
ture of iodine every third day.

This is a rare form of disease in man, but I have frequently
seen it in dogs, when it forms a hard lump attached to the end
of the long flexible auricle. In one instance that I rcmembery it
caused so much inconvenience to a valuable pointer, that it had
to be excised. Mr. Ogicr Ward has related cases of similar tumouis
in men and animab.

INFLAMMATIONS OF THE AURICLE

May occur idiopathically or from accident. Simple phlegmon is
not common unless induced by the stings of wasps or bees, when
the part swells to a great extent, but it seldom requires treat-
ment. In idiopathic inflammation the most efficacious treatment
is puncturing with a lancet, and the application of heat and mois-
ture. The lobe occasionally suppurates, and small boils frequently
form upon difierent parts of it, but their seat is chiefly round or
within the meatus, in the consideration of which part they will
be described. A German physician. Dr. F. Bird, has described a
form of inflammation peculiar to insane persons, in which the au-
ricle swells until, in some cases, the skin breaks, and the parts dis-
charge thick dark-coloured blood and serum. Having no expe-
rience of this affection myself, I wrote to a number of medical
friends connected with lunatic asylums, and although their state-
ments varied both as to its existence and cause, the establishment
of the disease, as affecting a particular class of the community in
this country, has been fully established. Dr. Thumham, of the
Wilts Asylum, who has had so much experience on the subject
of lunacy, is of opinion, that the disease has frequently been in-
duced by injury, and that, consequently, it was much more com-
mon when restraint was extensively used than at present

Acute erysipelatous inflammation frequently attacks the auri-
cle. It, as well as phlegmonous inflammation, may occur in con-
nexion with general otitis, and particularly inflammation of the
external auditory canal ; or it may be caused by the application

IM FLA KM AT IONS OF THE ADRlCUt- 167

oflceches, or by mechanical injury. Generally, however, itspreada
from the head and face, in which case a dep&t ofmatter irequentty
forma in the auricle aa well as in the eyelid.

Chronic erysipdaa is a frequent form of disease, particularly
among females in advanced life, in this country. Generally spesE*
ing, the patient hag first an attack of acute erysipelas of the head
and face. The ear, from being in such persons usually tied up
and excluded from the air, does not resume its natural healthy ap-
pearance along with the other parts affected, and the patient has
several repetitions of the disease in the ear alone, each attack
leaving the auricle more thickened and misshapen, until it be-
coues a hard, lumpy mass, finally rendering the meatus a mere
slit It is a most tedious and irritating disease. The following
cate (No. 23 in the Registry) is, with the accompanying illustra-
tion, a good example of the affection.

T. M., a female, aged 52, has had frequent attacks of erysipe-
las of her head and face during the last five or six years. The ef-
fects of the disease are, however, now ma-
nifest only in the external ears, but more
paiticuiariy the left. The auricle is not
muOi enlarged, but has become hard, in-
fieztSIe, and resembles a piece of wet,
thick sole leather ; its foses being appa-
rently filled up by' subcutaneous deposit.
It is also somewhat shortened in its an-
tero-posterior diameter. The skin is of
s dusty brown colour, without any exu-
dationt, eruptions, or crusts upon it, but
to the iect it is lumpy and nodulated, like
what we find in certain forms of elephan-
tiasis; the lobe in particular presents this
thickened appearance. The disease has extended some way in
IroQt of the tragus, which ie also thickened and lumpy ; and the
me&tua is nearly closed,

Dr. Kramer relates cases of " scirrhous degeneration" of the
auricle, but it would appear that he applied the term to affections
flimiUr to that now under consideration.

168 IVFLAMMATIOVS OF THE AURICLE.

The treatment of acute erysipelas of the auricle differs in no
way from the ordinary rules for the management of that disease
elsewhere, and that of the chronic form just described is so simi-
lar to the treatment of eczema aurium, given at page 170, that I
refer the reader thereto.

The various exanthematous eruptions affect the external ear
as well as every other portion of the body. It is, however, remark-
able, that although the ear is equally exposed with, and from its
situation more liable to, irritation from pressure than the face»
that it is seldom, even in the worst cases, marked with small-pox.

Gouty inflammation of the external ear has been fully estib-
lished. Dr. Graves, who was the first to describe this affection,
says, that the state of congestion of the auricle seldom lasts long,
and generally subsides on the occurrence of the disease in the ex-
tremities.

I do not think that cliitblains are now as common in this coun-
try as they were formerly, and perhaps this may be owing to the
manifest change which has taken place in our winter climate dar-
ing the last twenty years. In children and young persons ^o
suffer from these affections, the auricles are, from their expoied
position, particularly liable to be affected. In cold climates the
external ear is constantly frost-bitten. During the severe wnter
of 1840-41 the hospitals of Vienna presented numerous examples
of frost-bitten ^ars. At the same time scarcely a night elapsed
without a soldif r being frozen to death at his post.

Enlarged sebaceous follicles frequently present in the c«ncha
in pale, cachetic persons labouring under aural diseases. They
are easily recognised by their dark heads, and can be pressed out
with a pair of forceps.

CUTANEOUS AFFECTIONS OF THE AURICLE AND MEATUS.

Diseases of the skin of the auricle are by no means uncommtn,
and independent of the irritation which they produce, they iray,
if allowed to extend into the meatus, produce disease in the exter-
nal layer of the membrana tympani, and deafness. The most fine-
quent forms of skin disease in the auricle are eczema and herpes,

CUTANEOUS AFFECTIONS OF THE AURICLE. 169

but diseases of the scalp do not usually affect that organ. Syphi-
litic ulceration is by no means uncommon, and rupise are fre-
quently seated on the external ear.

The following case (No. 22 in the Registry) of eczema aurium^
with thickeninGT) and closure of the external meatus as a conse-
quence thereof, is highly characteristic : —

M. Q., a female, aged 60, has been deaf, •* off and on," for
several years past, accompanied by noise and wandering pains in
her head, with extreme itchiness in the auditory passages. The
skin covering the auricle, and the scalp adjacent thereto, is of a
fiery red colour, speckled with patches of yellow, formed by the
exudation which has collected in thin branny scales all over it.
The parts are hot, and in some places sticky, from a thin ichorous
matter which exudes from the surface. The auricle has lost its
natural shape, its folds and sinuosities being partially obliterated,
and it has become hard, thickened, and lumpy. The external
auditory aperture has, owing to the disease extending into it, been
lessened to a third of its natural size, and it is filled with branny
scurf. Upon removing the latter impediment, we can obtain but
a very partial view of the membrana tympani, which appears to
be thickened and opaque. Hearing distance, touching. The state
of the parts is nearly the same on both sides.

In examining diseases of the external meatus and auditory
tube like this, I find the small silver instrument, shaped like a blunt
gorget, figured at page 55, very useful.

Cases of this description, and, like this, of long standing, are
very hard to manage, because there generally co-exists some con-
stitutional taint, as shown in the cutaneous eruptions often mani-
fest in other portions of the skin, and because the parts now under
consideration have become so much altered in form and texture,
that it requires a long course of treatment to restore them to their
natural condition, and thereby re-establish their usual functions.
The disease principally occurs in females of middle and advanced
life ; but it also happens to children from six to twelve years of
age. In the latter, however, it is of a much more active nature,
ftt the same time that it is much more amenable to treatment. In
young persons the eruption often co-exists with scald head, and

170 CUTANEOUS AFFECTIONS OF TUB AUEICLB.

in both young and old, if the disease is allowed to exist for any
length of time, it extends into the meatus, and even over the sur-
face of the tympanal membrane, which it thickens and renders
opaque. In old persons a collection of branny scales accumulates
in the external tube; and in young persons a thick creamy dis-
charge coats over the lining of the canal and the external layer
of the mcmbrana tympani.

Cleanliness and attention are indispensable to the eradication
of these affections. In the first instance, continual poulticing with
any emollient substance which keeps up heat and moisture ia ne-
cessary. Linseed meal, boiled bread and milk, or well-mashed
turnips, will be found useful applications. Aflerwards, when the
extreme heat, swelling, vesication, and redness, have subsided, a
solution of the liquor plumbi, in the proportion ofa drachm to
the ounce, applied with several bits of fine lint, so as completely
to envelope the auricle, and the evaporation prevented by cover-
ing over the whole with a piece of oiled silk, rarely fails to lea-
sen the irritation, and reduce the parts to a healthy condiuon.
The solution ofgutta percha in chloroform, lately introduced
by Dr. Graves in the treatment of other skin diseases, I have
found a very admirable remedy in the chronic form of ecxema
aurium. The part should be painted over several times, until a
complete varnish has been laid on, when the greatest relief from
the heat and itching is experienced. The application should be
repeated from day to day, as the material soon begins to peel off,
but should never be applied until the acute attack has subsided.
When the auricle is shining, ofa bright red, and swollen, punctures
made with the point of a lancet, particularly in the helix, will give
great relief. In the chronic stage good may be effected by paint-
ing the part with a strong solution of nitrate of silver.

But while we employ these local measures, we must not neglect
constitutional means. Strict attention to diet should be enforced;
salt meats, savoury dishe?, and pastry, ought to be avoided, and a
sufficient quantity of fresh vegetables should be consumed at din-
ner. After the patient has been well purged, a course of Plum-
mers pill may be prescribed with advantage — at least, five grains
daily for an adult; and, in a little time, some of the preparations

CUTANEOUS AFFECTIONS OF THE AURICLE. 171

of sarsapariila administered in lime water will hasten the cure, and
assist to eradicate the disease from the system. This affection is
very apt to relapse, and we should, therefore, continue both our
local and constitutional remedies long after the inflammatory
symptoms have subsided. Old ladies think they never can have
a sufficient amount of warmth about the head, and it is very diffi-
cult to induce them to leave off even one flannel nightcap; but
we should at least make the attempt, as the head and ear ought
to be kept as cool as possible. As the swelling and inflammatory
symptoms subside, we should again turn our attention to the state
of the auditory tube. If any discharge exists, the meatus should
be syringed gently with tepid water daily ; and both it, the con-^
cha, and the tympanal membrane, washed over every second or
third day with a solution of nitrate of silver of the strength of at
least twelve grains to the ounce. Still more advanced in the pro-
gress of the treatment, when the exudation has completely ceased,
and the thickened cuticle has been quite removed, much benefit
will be derived from smearing over the tube and membrana
tympani with brown citrine ointment ( Ungt. Citrinum Fuscum)
every third or fourth day. It should be applied in a melted
state with a cameFs-hair pencil, and diluted by about one-third
of almond oil. This ointment, in which I have great faith in
all diseases similar to that now under consideration, should be
made with either rape-oil or cod-liver oil, instead of the olive oil
with the lard or butter usually directed in the Pharmacopoeias ;
it is then of a much darker colour, and never becomes hard or
crumbly.*

* There is no other medicine in the whole Materia Medica so frequently prescribed by
the practitioner which presents the same differences, both in appearance and effects, as the
ointment of the nitrate of mercury. Prepared as directed in any of the Pharmacopoeias
of the three kingdoms, it is impossible to procure it alike in any four different establish-
ments. It is found of all shades of colour,— straw-coloured, grey, green, yellow, orange,
and of every degree of consistence, dry and hard, or soft and pasty. If mixed with almond
oil, as in diluting it into an eye-salve, it soon becomes green, and gets a very unpleasant
smell, whether covered up or not, and in this state it is often very irritating. Many apo-
thecaries in Dublm do not adhere to the pharmaoopoeial formula, but make it up according
to a form of their own ; some use fresh butter instead of lard ; and others, difierent kinds of
oil, as from habit or experience they find best On explaining my difficulties, some years
ago, to Mr. Donovan, he procured me a citrine ointment of a very dark orange or brown

172 CUTAHBOUS AFFECTI0V8 OF THB AUEICLX.

Besides those eczematous eruptions, many other cutaneous di8>
eases affect the auricle, particularly in children. Excoriations
take place in infants behind the ears during dentition. There
is a popular belief that they are salutary. Cleanliness is their
chief cure when it is advisable to heal them up.

We have a disease in Ireland — so prevalent in some counties
that it would appear to be one of our national maladies — Pemr
phxgus Gangrenons, first described by the late Dr. Whitley Stokes^
and of which I have given a description in the medical memoir
attached to the Census of 1841. So fatal is this disease among
children, that no less than 17,799 deaths have been attributed to
1% in ten years ; and as it is a disease very well known to the lower
orders, I am inclined to think that the amount has not been ex-
aggerated. It goes under different local names, but the most
common are *• mortifying hive,** *• burnt hole," and ** black ear;*
the latter from its so frequently appearing behind the ears and
upon the auricles. In the Irish it is styled Ithdieadh, or the eating
disorder, from its phagedenic character. The vesicles, or bulls,
peculiar to this affection, generally leave an indelible and irre-
gular lace-like depression, similar to that of vaccination.

Lupoid and other wJiealthy ulcerations may either commence
in the auricle or spread to it from the neighbouring parts. I am
acquainted with, and possess a drawing of, a case of cutaneous can-
colour, soft, perfectly and equally smooth, and which docs not alter in any way by keep*
ing, by exposure to light, by mixing with oiU, or even by being gently heated to the
point of fluidity ; and it never acquires an add smelL Its therapeutic eflfects I hav* had
long experience of, and they are decidedly superior to those of the dntment in mianmi
use. Mr. Donovan has not made known its constituents, nor its mode of preparatioo.
lir. NichoUs has made for me a citrine ointment precisely similar in colour, aneU,
consistence, and effects, and he informs me that he usee rape oil instead of oliw oQ, aad
does not let the heat employed during the preparation exceed 200°. Mr. John Evans
has employed cod- liver oil, and also seal oil, and the preparations that produoed are ex-
ceedingly elegant and useful ones. Mr. Carroll likewise uses cod-liver oU in the conpo-
sition of this unguent. Messrs. Bewley have obtained for me a brown citrine ointmeDt,
somewhat like those already mentioned, and they inform me that it is by naiqg only tbe
very purest olive oil. I And this ointment a decided improvement on the old preparatioB,
and its composition should be investigated by those engaged in the prepttratioa of aaedi-
dues and pharmacopceias. When about to be used, it should be melted to the r'rwMCtf*^
of cream by placing the vessel containing it in hot water. It forms an aHnrfTuMff appli-
cation in ophthalmia tarsi, as well as in various diseases of the ear.

POST- AURAL TUMOURS. 173

cerous ulceration, extending from beneath the zygoma, which has
eaten away the tragus, and completely occluded the external mea*
tus. It remained nearly stationary for many years ; sometimes it
spread over the cheek, and at other times engaged a considerable
portion of the auricle. Its progress has usually been arrested by
the application of chloride of zinc In character and appear-
ance, as well as the peculiarity of the cicatrix which it leaves, it
greatly resembles that form of cutaneous cancer affecting the eye-
lid described by Dr. Jacob. Excessively irritable sores, with hard
elevated edges, frequently form on the external margin of the
helix, but true cancer of the auricle is very rare. Mr. Travers, of
London, has recorded a well-marked example, in which he re-
moved the disease. The auricle remained unaffected to the last in
those cases of malignant fungus of the ear which I have seen.

DISEASES OF THE MASTOID AND PRE-AURICULAR REGIONS.

As I have already remarked at page 56, the state of the mas-
toid region demands our most serious consideration.

Tumours behind the ear, and in any way connected with the
mastoid process, require the immediate and special attention of
the practitioner. Without entering too minutely into the subject
here, I may specify six kinds of post-aural tumours with which
I am familiar, and the situation and characters of which every
surgeon should be acquainted with, as some of them may prove
fatal in either the acute or chronic form.

There is a small gland lying upon the mastoid process imme-
diately above the insertion of the sterno-mastoid muscle, and on
a level with the tube of the ear, which sometimes enlarges to the
size of an almond : it becomes highly irritable and painful to the
touch, so as occasionally to resemble a neuroma. It generally oc-
curs in young females. I remember one such case which I attended
some years ago, and it was so painful that the lady could not bear
to have it touched. The external application of iodine, and the
internal exhibition of tonics, particularly iron, will in time remove
these tumours, but the cure is always very tedious.

The second form of tumour is also glandular, and of this I have
given an example on the next page. It is simply a suppurating

1 74 POST-AURAL TUMOURS.

gland, and is not unfrcquently met with in young children during
dentition. It generally appears in scrofulous constitutions^ and
very often in [)er8on9 who have suffered from some inflammatory
action in the middle ear or the external meatus. Such was the
case in the instance related below, as I learned from an inspection
ol* the tympanal membrane, as well as from the loss of hearing. I
never saw one of those suppurating glands, the great bulk of which
was not below the level of the external meatus, and this is a diag-
nostic of some importance, as a very formidable and often fatal
swelling, which sometimes occurs behind the auricle, is always
seated higher up. The treatment for this form of tumour is ge-
nerally such as was practised in the case described.

A. II., aged 19 (No. 3 in Registry), a grocer*s shopman, re*
siding in one of the back streets in an unhealthy part of the city,
applied at the Hospital on account of a tumoiur which existed be-
hind the right ear, and somewhat below the mastoid process. It
was about the size of half an orange, oval in shape, hard to the
touch, and of a purplish red hue, altogether very much resembling
the character of a syphilitic bubo. It did not give the patient
much uneasiness, and very little increase of pain was experienced
on pressing it; he had not had any pain in the ear or the side of
the head, and he says he never had otorrhosa. The tympanal mem-
brane is partially thickened and opaque ; he heard the watch only
when touching. The left ear was normal in function and appear-
ance. Although he stated that he was in his usual health, slept
well, and had his ordinary appetite, he was evidently an unheal-
thy subject ; his face was pallid ; his skin had a greasy aspect; the
pulse was small ; and the tongue large, white, and its margin much
indented by the teeth. He gave a very unsatisfactory account of
his disease ; said he never had syphilis, and bore no external mark
of scrofula. What was the original cause it was difficult to say,
and the patient appeared to be totally indifferent about his deaf-
ness. We sometimes find a patient remarkably apt and intelli-
gent in all the affairs of life who can give but a very meagre
account of the history or symptoms of any disease under which
he may labour, whereas other persons seem to be endowed with
a special and often morbid taste for medical details, so much so

POST-AURAL TUMOURS. 175

that they sometimes neglect their ordinary worldly concerns that
they may be able to talk over their complaints with any one who
will listen to them. The patient was directed to foment and poul-
tice the tumour ; to avoid exposure to cold, and to take some ape-
rient medicine.

This man did not return to the hospital until eight days had
elapsed, as he said the lump gave him little or no inconvenience,
and had opened two days ago. It then more than ever presented
the characters belonging to a suppurating gland in the inguinal
region. There was a large irregular opening, sufficient to admit
the top of the forefinger ; its edge was flabby, inverted, and of a
deep purple hue. The interior of the cavity was smooth, polished,
and of a dark red colour, totally devoid of granulations, and dis-
charging a thin ichorous matter. He had no headach, did not
sweat at night, but thought his strength and appetite were not so
good as usual. Simple dressing was applied to the sore, a table-
spoonful of bark mixture was ordered to be taken three times a
day, and the patient was recommended to remove some distance
into the country. Under this treatment the man recovered per-
fectly in a fortnight.

The third form of tumour I have only seen upon two occa-
sions ; it is a chronic abscess, very similar to lumbar abscess, and
is, like it, I believe, generally connected with diseased bone. I
remember a little boy at the hospital, about five years ago, who
laboured under this disease upon both sides, and of which I pos-
sess a drawing. Each tumour was about the size of half a hen- egg,
fluctuating, painless, and occupying all the bare space behind the
auricle ; the skin nearly of the natural colour, but traversed by
several blue veins. I opened these tumours, from each of which
poured a quantity of the usual scrofulous curdy matter. Almost
the entire of the surface of each mastoid process was denuded and
rough. The abscesses filled several times ; the child's health gave
way ; hectic ensued, and, missing it for some time from the Insti-
tution, I made inquiry and was told by the mother that it had
•* died of convulsions caused by water on the brain."

The fourth form of tumour is the result of acute inflammation,
either arising from periostitis of the mastoid process, and often

176 POST-AURAL TUMOURS.

extending over the entire parietal region; or caused by accuina*
lations of matter in connexion nfilh the mastoid cells, the result
of disease spreading from the middle ear ; or it may arise from
chronic inflammation and otorrhoea producing caries. With this
external manifestation we sometimes meet with diseased action of
a sudden and fatal nature going forward in the inner table of the
skull, or within the cranium, in the membranes of the brain, and
even the brain itself This form of tumour should always demand
our special attention, and the sooner we make a free incision in
such cases, not merely of the integuments, but through the peri-
osteum down to the bone, the better. Caries of the mastoid pro-
cess is by no means uncommon, but its consideration properly
belongs to the description of otorrhoea.

The iifth form of tumour is a true aneurism of the posterior
aural artery, of which there is at present a case in Steevens^ Hos-
pital, under the care of Mr. Colles, who has kindly permitted me
to make use of it.

A. F., a female, aged 27, states that four or five years ago she
perceived a buzzing noise in her right car, attended with an occa-
sional throbbing sensation, particularly on laying her head down;
that subsequently she applied for advice, and was syringed se-
verely, but did not receive benefit. About eighteen months ago,
she perceived a small, slightly pulsating tumour behind the auri-
cle, and having been informed of the dangerous nature of it^ she
lately came up from the country to have an operation performed.
The auricle is normal. On the mastoid region, occupying the
angle formed between the bone and the back of the auricle, there
is a pulsating tumour the size of an almond shell. It does not
convey to the fingers the usual aneurismal thrill, but upon the
stethoscope being applied to it, a well-marked l/rwt de aoti^^l is
heard. Its external covering is very thin, but natural in colour.
On compressing the artery with the point of the finger, near its
source behind the lobe, the tumour is immediately lessened in size,
and becomes flaccid, but resumes its bulk on removing the pres-
sure. When the sac is emptied, the bone beneath feels rough.
The membrana tympani is normal.

An endeavour has been made to apply pressure by means of

IVJUBIES OF THB MBATUS. 177

a pad, but owing to the curve of the mastoid process, where the
posterior auris artery is given off from the occipital, and the way
in which it lies into the angle formed between the auricle and the
bone, the pressure has not been effectual. Mr. CoUes purposes
tying the artery.

The sixth tumour which occurs in this region is a malignant
fungus, of which I have seen three cases: one in a boy aged 10,
the others in adults who had passed 50.

Abscesses often form in front of the tragus, and glandular swell-
ings of the side of the neck sometimes encroach upon the meatus,
and impair hearing. When the fascia covering the parotid, or that
gland itself, inflames, there is generally severe pain, throbbing,
and tinnitus in the ear, increased by the motions of the temporo-
maxillary articulation. The anatomical relations of the parts, and
the close approximation of the parotid gland to the lower and
anterior portion of the external meatus, accounts for the amount
of aural pain felt in these affections, and also in that denominated
mumps.

WOUNDS OF THE EXTERNAL MEATUS AND AUDITORY CANAL.

These injuries are rare ; they are generally produced either by
sharp penetrating instruments puncturing or lacerating the walls
of the passage, by extraneous bodies forcibly impacted therein,
or by the injudicious efforts of surgeons to remove them. I have
frequently seen the lining of the meatus lacerated, bleeding freely,
and subsequently sloughing from rude efforts made to explore the
canal. After the abstraction of the irritating substance, the treat-
ment of such injuries simply consists in subduing infliammation,
and allowing the punctured or abraded parts to recover with the
least possible degree of irritation. As in punctured wounds of the
orbit, so in injuries penetrating the external meatus, or the cavity
of the tympanum, a guarded prognosis should be given ; as we
know not when or where cerebral symptoms will arise which may
endanger life.

Hasmorrhage from the external meatus may occur from a va-
riety of causes, which, in a medico-legal point of view, it is of consi-
derable importance carefully to investigate and fully to understand.

178 FOaSIOV BODIB0 IV THB MBATU8.

For inttance« a dead body is found ; there is li»iiorrliage ficomone
or both ears; and medical evidence is required with respect to the
cause of death. Now, haemorrhage from the external ear may
arise from strangulation drowning, (?), concussion, fracture through
the base of the skull, asphyxia produced by difierent causes, apo-
plexy, and other congested states of the circulation, as wellasfidls
and blows upon the side of the head ; but, although this symptom
is thus enumerated among the post-mortem appearancea, the pi6f
cise cause of the haemorrhage, and the locality and amount of lesion,
have never been fully detailed. Bleeding from the external ear
may occur in the progress of disease, from slight accident, or from
the presence of polypus, or fungoid granulations in the meatus,
and the amount of haemorrhage is not in proportion to the extent
of injury inflicted. In the same way, that peculiar ^' welling up"
of serum — a well known characteristic of fracture of the base of
the skull, passing through the petrous portion of the tempoial
bone — has yet to be fully explained. As the ear is a part through
which fatal injuries might be inflicted without attracting the at>
tention of a superficial observer after death, I do not think the
subject of the post-mortem appearance of the ear has been suffi-
ciently investigated by medico-legal jurists.

FOREIGN BODIES IV THB AUDITOBT CANAL.

Foreign bodies sometimes get into the meatus by accident, and
are oflentimes, particularly among children, introduced by dengn«
The amount of pain and irritation which they cause is exceed*
ingly various. I remember being out shooting in a plantation
many years ago with a friend, who, suddenly exclaiming, ** Oh I
an earwig,** and throwing aside his gun, fell on the ground, mak-
ing the roost piteous moans, and rolling about in convulsive agony.
Finding that some small insect had got into his ear, I procured
some water from a neighbouring ditch and poured it into the mea-
tus ; and, as I watched for the result, a little animal, well known
among anglers as the hawthorn fly, crept out, and the gentleman
was immediately relieved. The fright experienced by the buning
of an insect in the meatus, as well as the pain and irritation which
it causes, can only be appreciated by those who have experienced

FOBSIGV B0DIB8 IH THB MBATU8. 179

that unpleasantness* The little animal denominated the earwig
{Fcr/ieula auricularis) is said to have a peculiar liking for entering
the external meatus, and the Dhor, or Dhor-deel {Gcerim olens)^ is
believed by the lower order of Irish to be fatal if it enters any of
the apertures of the body ; and many of the diseases resulting from
coldy or affections of the nervous ^stem which follow sleeping in
the open air, are attributed to this cause. The larvss of flies have
been found in the external meatus ; and these maggots, having
been removed, have in time turned into perfect animals. To dis-
lodge insects where they cannot be seen and seized with an instru-
ment, it is recommended to fill the meatus with oil, in order that
their spiracula, by becoming obliterated, and their respiration
thus impeded, they may be induced to creep out. This is a very
good popular recommendation, but a little warm water and a sy-
ringe will probably prove a more effectual means of dislodgement.
One of the latest English writers upon aural surgery, having re-
commended *' sweet almond oil** as the best remedy for dislodging
insects, reminds me of a quaint, and I rather think sarcastic, pas-
sage which I remember reading in one of Boyle*s papers, who, in
detailing the different cures said to have been wrought by marrow
extracted from the thigh bone of a man that was hanged, asks
whether the marrow from the thigh bone of any other man might
not answer as well. Many instances have been recorded of death
following the forcible introduction of foreign bodies, particularly
splinters of wood, into the meatus, either by passing through the
tympanal cavity into the labyrinth, or by exciting such inflammi^
Uon in the injured structures as, by extending to the brain, in-
duces disease in that organ. Peas and other seeds have been
known to germinate by being allowed to remain in the meatus.
No. 167 in ihe Registry is the case of a boy eight years of age»
into whose external meatus one of his schoolfellows thrust a grain.
(^Indian com. The schoolmaster, in his wisdom, endeavoured to
remove it by attaching a piece of wax to the end of a stick, and
thrusting it into the meatus. After an hour's ineffectual effort,
and the boy becoming almost convulsed with pain, he was brought
to a surgeon, who endeavoured to remove the offending body by
means of a forceps and other instruments. The haomorrhage, how-

o2

180 POBBIGV BODIES III THE HBATUS.

ever, which ensaed wm so great that it was deemed adTisable to
desist I saw the boj four days after : a profuse fcotid discharge
poured out of the meatus, on removing which the walk of the
canal were found to be lacerated and in a sloughing condition-;
while at the bottom of the passage the grain of Indian oomi <^a
yellow colour, and with several breaks and scratches upon its
smooth hard skin, caused by the instruments used to detach it,
was visible. The slightest touch of it caused the most excruciating
pain. With a curette similar to that with which I open the cap-
sule in extraction of the lens, — its point being bent nearly at a ri{^t
angle to the shaft, introduced cautiously between the grain of con
and the side of the meatus, and then giving the instrument a half
turn, — I succeeded in first twisting on its own axis, and eventually
bringing out, the grain of corn, which had, while in the ear, in-
creased to one-third more than its natural size. Fortunately the
membrana tympani, although highly inflamed, had not been rup-
tured, and the parts soon recovered.

A practitioner brought a child to my house, who, while play-
ing with some pebbles, allowed a small white stone to slip into the
external meatus si x hours before. She had not complained of pain ;
but the friends became alarmed, and were most anxious to have
the pebble removed, *' lest it might get into her brain.** Hehad,
he said, used various instruments, but without success, to extract
or dislodge the pebble. The child appeared then in great agony,
and the countenance was highly characteristic of the distress ex-
perienced. There was considerable haemorrhage from the ear,
and the external aperture had already begun to swell. Upon ex-
amination I found the meatus extensively lacerated, and could pes^
ceive and touch a white, rough surface on its anterior wall, but as
I felt sure that it was not the offending body, but the denuded
bone, I recommended, strongly against the wish of my firiend, a
cessation of hostilities, at least imtil the hssmorrhage had ceased.
A leech was applied to the margin of the meatus, and afterwards a
poultice placed over the ear. Upon visiting the patient next morn-
ing I found that suppuration had been established during the night,
and on syringing the ear with a little tepid water, the white quarts
pebble presented at the external aperture, and was easily removed

FOREIGN BODIES IN THB MEATUS. 181

with a forceps. Upon further examination, I found that the mem-
brana tympani had been ruptured anteriorly, and that the bone
was denuded for a considerable extent by the efforts made to eo^*
tract the foreign body. The parts, however, eventually resumed
their natural appearance.

Bits of slate pencil, glass beads, cherry-stones, paper balls, and
such like substances, are constantly introduced into the meatus ;
and it is remarkable, that the amount of suffering is no way com-
mensurate with the size or character of the substance introduced.
An intimate friend waited upon me late one evening in a state of
great anxiety, accompanied by his little boy, who, he said, had
put some glass beads into his ear in the morning. On inquiring
the reason of his not applying during the daytime, I was informed
that the child had not suffered the slightest inconvenience, and
had forgotten the circumstance until bed-time, when he men-
tioned it to one of the attendants. The beads were extracted with
facility.

A woman rushed into the hospital one morning in great alarm,
stating that a pin's head had got into her ear, and that several per*
sons had tried in vain to extract it. On bringing every portion
of the meatus into view, I was enabled to assure her that her fear3
were unfounded, when she went away perfectly contented, and
quite free from the pain she said she had previously experienced.

Rude efforts made to extract foreign bodies from the ear are as
likely to cause mischief as these bodies themselves. The simplest^
and often the most effectual, means of removing small substances
firom the meatus, is by syringing the meatus with plain warm
water. If the offending body is not producing much pain or an-
noyance, it is scarcely fair to the patient to introduce some rough
instrument into the passage, in the hope of dislodging it, without
the use of the .speculum, and bringing the foreign substance well
into its field. The operator, merely dilating the external aperture
with a divaricating speculum, gets a glimpse of the offending
body, — a piece of slate pencil, a small pea, or a bead, — and pass-
ing down an ordinary dressing forceps, the blades of which so fill
the aperture that he must then work by touch and not by sights
attempts to seize the smooth, round, slippery substance, which

188 nrjuuis of ths ksatus.

10, at each effort, pressed down upon the m^nbrana tTmpani,
thereby not only eluding his grasp, but producing the moat ex-
quisite torture.

The head should be placed against some lensting bodj, or
firmly supported in an operating chair, and the canal brongfat fairly
within the field of the speculum ; then the curette, or the amall
silver spatula figured below, acting either as a lever or a hook,
will, if proper care be taken, in almost every instance dislodge
the substance; and if it has got into a podtion where it cannot be
well got at, syringing will often alter it so as to present some point
where it may be either seized with the forceps without pving
pain, or where we can easily introduce the curette between it and
the wall of the meatus, and so extract it Where we employ a
forceps, that figured at page 57, or the one represented along with
the spatula in the accompanying wood-cut, will be found useAiL

The ingenuity and dexterity of the operator will, however, sug-
gest the most feasible mode of operating.*

When it is remembered that death has firequently followed
the introduction of a foreign substance into the meatus; and that
epilepsy and many other distressing symptoms have ensued from
the same cause ; and when every practitioner who has met with
cases similar to those detailed must have experienced some of the
difficulties to which I have alluded, the foregoing observations
will not appear too long.

Acids have been poured into the ear either by accident or
design, and have produced frighful agony, and even death. How
far poisons act when introduced through the meatus has not yet
been fully determined ; but the idea that they induced fatal re-
sults was current in England in the days of Shakespeare, and still
prevails among the Irish peasantry.

* TImm initnuMots an itpw— teJ thiw-fiNirtlia Uw natonl

DI8BA8B8 OF THB CBBUMBN0U8 QLAKD8. 183

DI8SABE8 OF THB OBRUMBNOUB GLAKDB.

One of the most common and curable forms of deafness arises
from impaction of the auditory canal with hardened wax. In
cases of recent accumulation the dark, shining, convex end of the
plug may be at once perceived on inspecting ihe meatus ; in those
of long standing, where the fluid portion has been evaporated,
the offending material, mixed with hairs and scales of cuticle, has
generally a concave surface, is not polished, and is seldom so dark
as in the former case. At times the scale of hard wax is not
thicker than a half-crown piece, and adheres firmly to the outer
surface of the membrana tympani, causing impairment of hearing
and most distressing tinnitus.

Gases of deafness proceeding from accumulation of cerumen
are so numerous and so easy of cure that it seems unnecessary to
occupy space in describing them, while so many other diseases of
the ear present themselves more worthy of our attention, because
less known and more difficult to treat. Yet let me say that the
ability of making a diagnosis in such cases is not always possessed
even by good surgeons and physicians. From week to week
I meet with cases of deafness attended with tinnitus aurium,
which have been ascribed to and treated as depending upon func-
tional or organic derangements of other organs, the stomach and
the brain in particular, and for which constitutional means as
well as topical applications had been employed at considerable
length, but which, upon examination, proved to be nothing more
than firmly adhering pieces of hardened wax.

A medical friend in the country wrote to me to say he had
become suddenly deaf in one car ; that he applied to a neigh-
bouring surgeon who syringed him ^* for a long time ;" that only
a little wax came out; whereon he had taken aperient medicine,
filled the meatus with cotton steeped in brandy, and applied a
blister over the mastoid process. As I could not possibly advise
him what to do without knowing what was the cause of his deaf-
ness, or, at least, having, by means of ocular inspection, a certain
amount of positive and negative symptoms to judge firom, he
came to town, when I found a layer of hard dark wax pasted over

184 DI8BA8K8 OF THB CBftUMSVOUS COiAVIML

the membrana tympani, which was easily lifted off with aspatala,
but which no syringing would have removed. All his symptoma
immediately disappeared.

If we examine the membrana tympani after the offending sub-
stance has been removed, we will in most cases find it vascular,
and the lining of the canal pinkish. To judge, however, from
this state would be most erroneous, as the irritation produced by
the removal of the wax necessarily gives rise to the vascular cob*
dition alluded to. Persons who perspire much about the head
seem to be more liable than others to collections of cerumen.

Unless illuminated by some means, natural or artificial, the
external auditory passage is a dark cavity, and, without proper
inspection, it is not possible to know, by any set of symptoms of
which the patient himself is conscious, whether his disease pro-
ceeds from the simple mechanical impediment of a plug of wax,
disease of the middle ear, or threatenings of serious mischief in
the brain itself, because the two most prominent symptoms,
deafness and tinnitus aurum, are common to all three, and to
many other diseases of the ear also ; in the same manner as we
find impaired vision and muscse common to so many diaeasea of
the eye, as well as symptomatic of cerebral and other affections.
I see few cases of incipient cataract in the upper ranks of life
which have not already undergone a little doctoring, under the
impression that the disease depended upon the state of the sto-
mach ; and blue pills, bitter mixtures, and dietetic regulations^
have had full sway. But, where so much has been achieved for
medical science during the last twenty years by greater attention
to diagnosis, thus rendering the healing art a moro accurate
science than heretofore, I do not think it is too much to ask the
practitioner to possess himself of a small tubular speculum, and to
take a peep at the state of the parts he is prescribing for, before
he resorts to the routine treatment alluded to. This is, properly
speaking, one of the errors of omission. Now I will state one
of commission. A patient is seised with deaftiess and a singing
noise in one of his ears. The medical attendant, supposing it might
be wax, squirts hot water with a powerful syringe into the audi-
tory passage for half an hour together, and as nothing cornea

DISBA8B8 OP THB OBBUMBVOUS GLA»D8» 185

oat, he syringes the harder. All this time the patient laboured
under inflammation of the drum of his ear, which, I need not
say, was not improved by the treatment adopted. Let me entreat
of my readers never to syringe an ear, nor to drop any stimulating
application into it, until they have carefully examined the state
of the parts, and assured themselves of the presence of wax or
other foreign body. My advice was sought by an officer, for
deafness caused by thickening of the membrana tympani. On
asking his medical attendant what treatment he had employed,
he said, *' I syringed him every day for three weeks, but nothing
came out** I

The cerumenous glands are more liable to morbid changes
than the profession are aware. The. moment an inflammation is
set up in the neighbouring structures they cease to secrete. When
otorrhosa is present, their function seems also suspended. At
times they secrete a thin, light-coloured, honey-like cerumen,
so quickly and in such quantity as to pour out of the external
meatus. This I have chiefly seen in weakly females, and often
occurring as a sequel to some febrile attack. It is the analogue to
inflammation of the Meibomian glands. From children of a year
old to persons of extreme age we meet with collections of hard-
ened wax in the ear, and are called upon to remove them ; but
they are more frequently seen in middle life than at any period
antecedent thereto. They are not always accidental, as we learn
firom the same person returning again and again, at intervals of
two or three years, to have them removed. The vitiated secretion
probably depends upon some chronic inflammation of the ceru-
menous follicles themselves. The wax is generally darker in
colour than natural, at times resembling pitch in its tenacity and
hue. In other cases, it becomes as hard as a piece of mortar or
concrete, and forms an accurate cast of the meatus auditorius ex-
temus, feeling to the touch of an instrument like a stone or foreign
body. As soon as this has occurred hearing is much impaired ;
but from time to time the patient feels a slight report in his ear,
particularly afler eating or moving his jaws, and then the hearing
is much improved for a short period. The improvement is caused
by the motion of the external portion of the tube slightly disad-

186 VUMASMB OF TBM GEEUMEIOini 0MMP6L

justing the cork of wax, and so allowing air and sound to be
temporarily transmitted to the dnim*head; but the improTiraiieDt
is lost as soon as the plug has regained its former poeitiout or an
additional deposit of wax fills up the space, and again oodndes
the air and sound. This circumstance, triyial as it is, is worthy
of note, because something very similar takes place in another
disease of the ear, arising from a totally different cause. In
catarrhal inflammation of the middle ear, with thickening of the
lining membrane, or mucous collections within the Eustachian
tube, or thecavitas tympani, we perceive, as perhaps many of m
have ourselves experienced when labouring under catarrh or in-
fluenza, a sudden report, as if something gave way in the ear, fol-
lowed by an immediate accession of hearing. In some eases of
complete impaction of wax, particularly where it is very bard and
of long standing, the patient does not hear the watch, even when
held to the auricle, pressed agunst the mastoid process, or laid
upon the forehead — symptoms generally indicative of some grest
lesion of the internal or middle ear, or paralysis of the auditoiy
nerve ; — ^yet as soon as we have removed the mechanical impedi-
ment, the hearing becomes exalted to a degree which is painful
to the patient to bear. I cannot but think that, in such oases,
the loss of power has arisen from the pressure exerdsed by the
foreign body upon the tympanal membrane, and, through it|
transmitted by the chain of ossicula to the labyrinth.

Squirting hot water into the auditory passage, even with the
most powerful syringe, will not always succeed in removing the
ofiending body. In fact, if not properly done, it rather increases
the impaction. I have, however, seldom met a case in which,
with a little care and patience, I could not remove the wax at one
sitting. One of the cases which proved an exception to this was
in a person who had a natural hour-glass contraction in the mid-
dle of the passage, and another where there was an exostosis
the size of a split petk in the same locality. The best syringe
to employ is that figured at page 77, worked with the right
hand, while the led grasps the top of the helix, and, by drawing
it slightly upwards, outwards, and backwards, assists to straighten
the meatus, and thus facilitate the exit of the plug of hardened

DI8BA8B8 OP THE OEBUHXironS OUSDS. 187

cerumen. The jet of fluid should not be directed point-blank
against the cork of wax, but rather to its edges, -where it is at-
tached by a number of hairs, and is often intimately united with
the cuticle. From time to time we should introduce the specu-
lum and see what progress is being made. The fine long-bladed
forceps may sometimes be slipped down upon the ofiending body,
and it can be thus withdrawn ; or, what I find much more useful,
the small silver spatula already described, and which, acting as a
lever, moves the plug, and so allows the water to get behind it
and force it out Another instrument very useful in such cases
18 a fine blunt curette, made of silver, and with the end bent
for about a line in length at a right angle with the shaft, referred
to at page 179. By slipping this down between the cork of hard
wax and the wall of the meatus, and then, when it has proceeded
some distance, giving it a half turn, so that its point fixes in the
plug, the latter may often be removed en masse. Care must, how-
ever, be taken in using these little instruments not to abrade the
akin, which at the lower portion of the meatus is very delicate,
and apt to bleed upon the slightest irritation.* We read in books
on aural surgery, and in lectures and details of cases given in pe-
riodicals, of various substances employed for the purpose of soften-
ing wax — the last of which was glycerine ; but, if attention is paid
to the directions I have now given, some patience exercised, and
that we proceed with care and delicacy, I do not think we need
often have recourse to any of the nostrums recommended for
softening and removing wax. Should we, however, at first en-
counter any difficulty, or the patient experiences much pain from
our manipulation, it is better to desist, and drop a little warm oil
into the ear once or twice a day, or keep a bit of cotton moistened
with oil in the passage, until the wax has been partially softened.
Simple removal of the wax will generally restore the hearing
at the moment, but the tinnitus oft;en remains for some time after.
As a consequence of impaction of the auditory passages with ce-

* The ear-pan fignied at page 76 will be fbnnd a yeiy oonyenient, cleanly inatru-
BMBt I have latterlj placed the perforated division acrois one end instead of along die
length of the paOk

188 DI8BA8B8 OF THB CSBVHSVOUB OLAXM.

rumeny producing thiokeninff of the cuticolar layer of the mem-
brana tympani, the two following Cases may be cited: —

L. W., a male, aged 40 (No. 14 in the Registry), applied on
account of deafness in his left ear of some weeks* standing, but
which had recently increased very much. Complains of noiae like
that of a boiling kettle. Hearing distance, two inches; says it
varies from time to time, but that it was always better after eating
until lately. Occasionally he experiences a loud noise, as if a report
took place in his ear, after which the hearing is improved. £Bs
disease has been of twelve months* standing. Upon examination, I
found the external auditory passage filled to its aperture with hard,
brownish, inspissated cerumen. It is so hard, that percussion with
a probe conveys the sensation to the fingers as if stmck against a
body as firm and resisting as stone. Numerous short but firm haiis
grow around the external aperture, and some of the more internal
ones are probably mixed up with the hardened cerumen, and so
assist to keep it immoveably fixed in its place. The mere projection
of a stream of warm water from a syringe will not easily remove
such a thoroughly impacted mass as this. It must be assisted out
with the spatula, slightly bent at the end, like the old lever used
in midwifery ; but the ear should be syringed from time to time
as we proceed with our manipulations. When well loosened, I
removed it en masse with a pair of fine forceps, and perceived that
with it came out a large collection of hairs, which had become
entangled within it; and that all its lower portion and its extre-
mity was covered over with a layer of soft, white, thickened cu-
ticle, the natural lining of the surface with which it has been so
long in contact, thickened and separated by the pressure exercised
upon it by this foreign body. Immediate relief to all the symp-
toms under which this person laboured was experienced by the
removal of the foreign substance. The hearing increased to
twelve inches, and the noise lessened considerably. Upon inspec-
tion through the speculum, the membrana tympani was seen
whitish and succulent, and having the parboiled appearance of
the piece of cuticle which had been removed from it. Several
large red vessels also ramified upon its surface, and coursed along
the insertion of the malleus in particular. This condition wa^

DI8BA8B8 OF THE OBBUMEROUB OIAlTDe. 189

no doubty caused by the pressure of the accumulated and hardened
cerumen ; but in a few days the part recovered its natural cha-
racter.

Several times during the removal of this wax the patient was
seized with a fit of spasmodic coughing, apparently caused by
some irritation in the larynx. I have already alluded to this pe-
culiar phenomenon at page 77. Since that portion of this work
was printed, I met the following observations in the British and
Foreign Medico-Chirurgical Review, vol. xvii., p. 414: —

'* Pruritus of the external meatus auditorius, from hyperaes-
thesia of the auricular branch of the pneumogastric, is sometimes
observed, and is accompanied by cough and vomiting. This con-
nexion between the car and the stomach and lungs is not suffi-
ciently remembered by modem practitioners. Arnold mentions
an interesting example of chronic vomiting in a child, which
long resisted all curative means, but which was effectually re-
moved by removing a bean from each of the child's ears that had
slipped in while at play. Cassius Medicus has for one of his
problems, — Why does irritating the ears, as, for example, with
a speculum, cause sometimes a cough, just as if the trachea was
irritated?"

No. 5 in Registry, M. B., aged 25, a literary teacher, com-
plained of general deafness, with singing noise in both ears. Upon
inspection, the external auditory passages were found to be corked
up with hard inspissated cerumen. This was removed by syringing
with warm water in the ordinary manner, upon which the hearing
was quite restored in the right and partially in the left ear. A few
days having been allowed to elapse, in order that the meatus and
external surface of the tympanal membranes might regain their
ordinary appearance after the vascularity produced by the pressure
of the wax, and the excitement and irritation caused by its remo-
val had subsided, this case was again examined.

Right Ear. — Hearing distance, two feet and a half; the mea-
tus dry, but no appearance of disease presented upon inspection
with the speculum.

Left Ear. — Hearing distance, four inches ; walls of meatus co-
vered with flakes of thickened whitish cuticle, which presented

190 IVfIi4]fHATI0St or THB IZTSUUL MB4Tm.

the Appeanmoe of partial maoeimtioii, and neaily filled up tbe
vity. Upon removing these with a forcepa, the saifiu^e beneath
presented a florid red coloor. The membrana tympani was thick-
ened throughout, and exhibited patches of vascularity, which deep-
ened into a continuous red surface above and behind the inaerUaa
of the malleus. He had a confused rustling noise in this ear. The
Burhce of the meatus and the membrana tympani was washed
over with a solution of nitrate of silver, five grains to the ounce;
a dose of aperient medicine was prescribed for him, and he was
directed to wear a bit of cotton wool in the external aperture, so
as to exclude the cold air. In ten days this case was again in-
spected. Tbe meatus on the left side had resumed its natuial
colour, but was very dry and somewhat scaly. The tympanal
membrane had cleared considerably since last report; the lower
portion in particular had become quite free from vascularity, but
a few large vessels could still be observed coursing behind the
manubrium. He could inflate the tympanal membrane after the
manner described in the former cases. The hearing distance had
increased to fourteen inches; the noise had very much lessened,
and occasionally intermitted altogether. The surfiu^e of the mem-
brana tympani was again washed over with the soluUon of caustic,
and the walls of the meatus smeared with brown citrine ointment,
applied in a melted condition.

The chronic inflammation of the entire external auditory apei^
ture in this case appears to have been the result of mechanical pres-
sure, and the irritation of the hardened wax.

IVFLA1IMATI0H8 OF THB BXTBBHAL ADDITORT CUTAL.

Inflammations of the external meatus and auditory canal are
of very common occurrence. To follow out the anatomical prin-
ciple of classification pursued by some authors, these inflammations
should be divided according to the structure in which they have
their seat; but, as all practical surgeons are well aware, it is no
more possible to do so than it is to limit the spread of these in-
flammations. Thus, what may commence as a simple inflamma-
tion of the tegumentary tissue, may end in caries of the bone and

INFULMICATIOMS OF THE BZTBBVAL MBATUS. 191

inflammation of the brain or its membranes. I have, thereforei
adopted the arrangement specified in the nosological chart, and of
which the following is a description : —

Abscess in the external meatus is one of the most painful and
firequent inflammations of the external ear. Grenerally it is not
like the difiused form, the result of cold, but seems to be induced
by some peculiar state of the constitution, and very often appears
either as the sequel to or a concomitant of boils on other parts of the
body, particularly about the neck. These abscesses are more fre-
quent in females than in males ; and, I am inclined to think, appear
oftener in persona of the upper walks of life than those in the lower.
They may be seated anywhere all round the external meatus, but
occur more frequently in the anterior and posterior wall than in
the roof or floor. They may not exceed a pea in size, or they may.
advance to that of a large marble, or even a walnut, when, if
seated anteriorly, they spread in front of the tragus, and if poste-
riorly, they present a considerable protuberance over the mastoid
process, so as to be distinguished with some difficulty from in-
flammation, and deposits of pus beneath the periosteum in that
situation. They seldom or ever appear singly : there is generally
a succession of them, and of this the patient should be informed
on first applying for advice. There is not much redness of the
part; the heat is more of a burning or itching character. The
pain, however, is most intense, aggravated by the slightest touch,
and always increased at night, and also by any motion of the jaw.
In addition, there is always more or less tinnitus, and a feeling of
stuffing, buzzing, and throbbing in the ear. The fever is at times
considerable — much more so than would be expected from so
slight a cause, and characterized, not so much by alteration in the
circulation, as by evening paroxysms, heat of skin, restlessness,
and great anxiety of countenance. From the structures in which
they are placed, these abscesses are generally a long time coming
to the surface, and they almost invariably point internally, or to-
ward the centre of the external orifice. The contents of each ab-
scess— which is the analogue to a stye upon the eyelid, but, owing
to the structure in which it is placed, it is far more painful — con-
sists of thick yellow pus and a hard core of dead cellular membrane ;

198 DrFUMlIATIOV OV THB BXTlUrAL HBATUS.

the former is sometimes only s drop, at other times it is as modi
as a drachm.

The local treatment, most efficacious for preYentiDg suppora-
tion in these parts when inflammation has been set np, is the appli-
cation of the solid nitrate of silver so as to blacken the skin. Ab
soon as we believe matter has formed, and come some way to the
surface, but not till then, we should make an incision with a veiy
small double-edged knife. At the same time fomentations and
poultices, and holding the ear over the steam of hot water, will
afford relief both before and after the matter has been evacuated.

Few diseases of the ear require more careful constitutional
treatment than this. After attention to the state of the digestive
organs in the usual fashion, the use of bark, with either the li-
quor potasss or Brandishes alkaline liquor, will assist to prevents
recurrence of these abscesses. While the abscesses in the exter-
nal meatus are appearing in the manner described above, there is
generally some subacute inflammation of the lining of the whole
canal, attended with a whitish discharge, and in some cases the
membrana tympani is itself inflamed, so that we should, as soon
as the parts will permit, examine the condition of that structure.
If inflamed, leeches are indicated ; but unless applied in the very
early stage of circumscribed inflammation, they seldom prevent
the formation of matter.

Diffused inflammation of the external meahu is a matter of
much more serious consequence than either the profession or the
public are aware ; for, frequently as it occurs, and lightiy as it is
treated, it generally ends in the establishment of a disgusting dis-
ease— otorrhoea, which always impairs the hearing, oftentimes
leads to total deafness, and, in some cases, ends in death. Yet
how frequently do we hear practitioners speak of the patient hav*
ing '' only a slight discharge from the ear.** At times the symp-
toms of inflammation of the lining of the meatus are so slight, and
produce such little uneasiness, that the patient first becomes con-
scious of his disease by feeling something wet in his ear, when
upon applying the finger, or a towel, he discovers that a discharge
of thin, whitish, muco- purulent matter^has been established; or
in infants and young children, about the period of dentition, the

IHFLAMMATIOHS OF THB BXTBaNAL MBATUS. 193

nurses and attendants observe the flow of matter as the earliest
symptom of the disease. This is the subacute or catarrhal inflam-
maiion of the dermis, and the external layer of the membrana
tympani, which is always attended with otorrhoea, and which fre-
quently remains in a chronic condition for years. The state of
the external aperture on the first onset of the disease, and before
it has become thickened or excoriated by the discharge, is nor-
mal ; but within, the cuticle is white, pulpy, and detached, and
the skin beneath it is usually of a pinkish colour. This is a dis-
ease of infancy and youth, and is one of the most decidedly stru-
mous affections with which I am acquainted, not only from its
appearing in persons of well-marked scrofulous character, but from
its being so frequently a concomitant of other scrofulous affec-
tions, particularly of the lungs. Out of 2385 cases recorded in
the Table at page 102, there were 516 of chronic otorrhoea, the
males predominating somewhat over the females.

Aettte inflammation diffused over the external meatus may be
either idiopathic, as fro£ cold ; traumatic, from a foreign body
or any irritating substance introduced into the meatus ; or spe-
cific, as when it occurs in the course of some of the exanthema-
tous fevers, is produced by infection with gonorrhoeal matter, or
is attended by such other symptoms in persons where there is a
decided diathesis that it may be termed rheumatic. This latter
need not end in suppuration or otorrho&a; the previously specified
forms generally do. To these different forms of inflammation,
classified in the nosological chart at page 147, 1 have added that
of periosteal, to define that particular kind of inflammation usu-
ally accompanied with otorrhoea, which, sooner or later, spreads
to the periosteum and the bone of the auditory canal, and from
thence to neighbouring structures, often producing fatal conse-
quences. When once a discharge is established, no matter from
what cause, but more particularly when it results from subacute
or chronic inflammation of the lining of the meatus, and the ex-
ternal surface of the membrana tympani, — which, in such cases,
generally becomes muco-secreting, — we have then a special dis-
ease to treat, denominated external otorrhooa, which shall be con-
sidered in the chapter upon that subject.

p

194 iMWiAMMk'AomB or thb mxrmaaAL mbatub.

Acute inflammation of the meatus can weueelj exist, or pro*
cecd to any extent, without engaging the external layer of the
membrana tympani. The inflammatory action may be limited to
these two situations ; where known, the disease is characterised by
Tiolent pain and fevers it seldom is so, but usually engages the
mucous membrane of the cavity of the tympanum, as is proved
by the frequent rupture of the membranous diaphragm between
these two portions of the auditory apparatus. Such is generally
the case in those inflammations attending eruptive fevers, scarla-
tina in particular, where the mucous membrane of the throat and
ear, as well as the glandular structures of the neck, are, in the s^
vere instances of that affection, so frequently engaged ; but ia
these latter I am inclined to think the disease spreads to the audi-
tory organ more frequently from the throat than the skin.

Acute inflammation of the meatus is characterised at first by
dryness, itching, and heat of the part, gradually increasiDg to a
dull aching, and eventually to an acute lacerating pain, generally
increased at night, and in some instanc^ amounting to insufiera*
ble agony, with loss of rest, fever, and even delirium. The lining
of the meatus is swollen: at first dry and pinkish, then white and
muculent ; and at that stage I have on several occasions seen the
whole of the bony portion of the tube and the external surftcsof
the membrana tympani coated with a layer of plastic lymph. In
a short time a scro-mucous or muco- purulent discharge is estab-
lished, or yellow pus pours from the meatus, and relief is thai
generally experienced. Attendant upon these feelings and ap*
pearances there is, particularly in rheumatic cases, a sensation of
soreness over that side of the heud, and all the symptoms are in*
creased by sneezing, coughing, chewing, or moving the jaw in
any manner. As, however, the hemicranial pain, and many td
the other symptoms detailed, are common to inflammations of the
cavitas tympani and general otitis, it is often difficult to distin-
guish external from internal inflammation of the ear. The fol*
lowing case of acute inflammation of the external auditory tube
and membrana tympani (No. 16 in the Registry), is characteristic
of this afiection : —

T. S., aged 46, a shopman, complains of deafness in his left

INFLAMMATIONS OF THE SZTSBNAL MEATUS. 195

ear, of a fortnight's duration, accompanied by a buzzing noise and
throbbing. The disease commenced late in the evening, with se-
vere pain, which continued all night, and which, although miti-
gated, has never entirely ceased since, but is always most distress-
ing at night. Upon the fifth or sixth day he perceived a *^ slight
moisture'' in his ear, but was not conscious of any sudden burst, or
a feeling as if something had given way within. The external
meatus and auditory tube, as well as the surface of the membrana
tympani, are coated over with a tenacious muco-cerumenous dis-
charge, upon the removal of which the entire surface brought into
view appears of a florid red, becoming pinkish and spotted with
ivhite on the face of the membrana tympani. Flakes of cuticle
adhere to the walls of the canal. The spots on the membrana
tympani appear to be patches of lymph effused on its surface ;
they are more of a yellow colour than the specks of cuticle on the
tube. The membrana tympani is still imperforate. We occa-
aionally find the whole surface of the tympanal membrane covered
over with a sheet of lymph like that which lines the trachea in
cases of croup. He cannot hear the watch even on touching.
On the right side the parts are healthy, and the hearing good.
The treatment recommended to the patient has only aggravated
his disease, — brandy and oil, laudanum, hot salt, and various sti-
mulating applications, having been poured into the meatus.

This is a case too manifest to be mistaken ; and, from the to-
tal loss of hearing upon the left side, it is probable that the inflam-
matory action has extended to all the layers of the membrana
tympani, and has also passed into the cavity of the middle ear.
Had it commenced in the latter, the pain and attendant fever
would have been greater, and, on suppuration taking place, the
membrana tympani would probably have been ruptured to allow
the exit of the matter, and the case would now be one of internal
otorrhosa, with perforation. Cases of this nature are very common
during the winter months, or when cold east winds prevail in
March and April ; and are frequently induced by travelling upon
the top of a coach, sitting opposite an open door or a broken
window, or being exposed to a draught of cold air in any situ-
ation. I am frequently consulted by Roman Catholic clergymen

p2

196 nrFLAMM ATIOVS or TRB XXTSBVAL MBATU8.

during the season of Lent, for inflammation of the ear ftcquiTed
while sitting in the confessional-box, often for hours together, in
cold, exposed places of worship, with the ear applied to a small
aperture through which the wind is playing. In the foregoing
case, local depletion, continued counter-irritation, and altermtiTe
doses of mercury, restored the parts to a healthy condition, and the
hearing returned. In some cases of inflammation of the auditory
canal, the auricle is hot and swollen ; but in no instance does it
erer assume the osdematous character which the eyelids present
in severe ophthalmia.

The treatment of acute inflammation of the external auditory
conduit should be strictly antiphlogistic. Local depletion, by
means of leeches applied round the meatus, or the neighbourhood
thereof, after the manner described at page 85, is indicated in
almost every case. Purgation is always attended with advantagOt
and the patient experiences great comfort from the application of
heat and moisture. Mercury is seldom indicated unless when the
membrana tympani is deeply implicated. Counter-irritation should
follow, but unless in mild cases, never precede, depletion. Astrin-
gent lotions should be used with caution until the disease is in a
subacute or chronic form, when it becomes a case of ordinary
otorrhoea. I have seen small granulations sprout from the lower
portions of the canal within eight or ten days after the first acoes-
sion of inflammation of this portion of the ear, but generally
speaking they occur at a much later date, and are more usually
attendant on disease of the deeper-seated structures. Superficial
ulcers form both on the dermal lining of the meatus and the ex-
ternal layer of the membrana tympani.

Continental authors have enumerated gonorrhaa among the
causes of inflammation and otorrhoea from the external meatus,
and upon the authority of writers I have inserted this disease in
the nosological chart, although I myself have never met a case
that could be fairly traced to it, either by metastasis or the direct
application of specific virus to the part. Mr. Harvey, of London,
wrote an essay on venereal aflections of the ear, in the London
Journal of Medicine for February, 1852, in which he alludes to
the analogy between ophthalmia neonatorum and in&ntile otor^

niTLAlCMATIOHS OF THE BZTBRNAL MBATUS. 197

rhoea produced by the contagion of specific matter. I must, how*
ever, for my own part, confess, that I am unacquainted with that
^ obstinate form of infantile otorrhcda which occurs shortly after
birth, not unfrequently destroying the organ, and producing as a
consequence both deafness and dumbness for life," alluded to by
the author* In order to trace it to infection by direct contact, the
disease ought to appear within the first fourteen days at the latest
after birth, whereas every accoucheur, or physician familiar with
the diseases of children, is well aware that the muculent discharge
of infants does not in general appear until after the second month,
and still more frequently not until dentition commences* The
case related by Mr. Harvey does not support his hypothesis, or
bear scrutiny. A man labouring under gonorrhoea and hernia hu*
moralis is '* seized with intense itching in his ear, accompanied
with paroxysms of pain ; and shortly afterwards there issued a pro-
mise yellowish discharge." To account for the disease the author
says, ** Let us suppose the man's finger to have been soiled with
the urethral discharge, and that on an occasion of an intense de«
gree of itching in the external ear (the very first symptom com-
plained of by the patient), he had thoughtlessly and with some
violence thrust his finger into the meatus, possibly abrading the
membrane with his nail." He also quotes Lincke's description at
length, but it does not contain any one diagnostic wherewith to
distinguish this form of inflammation firom that arising from any
other cause, and we require experiments to establish the fact that
the external meatus is susceptible of gonorrhosal infection.

Whatever may be the cause of the inflammation in the lining
of the meatus, the diseased action, once set up, may spread sooner
or later to the periosteum and the bone, causing necrosis, exfoli-
ation, cerebral disease, and death. It is, therefore, a disease at all
times demanding the serious attention of the surgeon, and requir-
ing prompt and energetic measures for its arrest. Mr. Toynbee,
in an elaborate and ingenious article in the Medico-Chirurgical
Transactions, vol. xxiv., has endeavoured to show that disease of
particular portions of the ear are propagated from or give rise to
disease in particular portions of the brain ; thus, when inflamma-
tion or its results is seated in the external meatus or mastoid cells»

1 98 CUTAVB0U8 DI8BA8B8 OP THS HBATUB.

the cerebral affection will be found in the lateral rinns and cere^
bellum ; from the tympanic cavity, disease is propagated to the
cerebrum ; and from the labyrinth to the medulla oblongata and
base of the brain. The author has collected and arranged in a
tabular form a number of cases of death produced by extension
of disease from the ear to the brain, or its membranes, in which
post-mortem examinations were made ; but although these cases,
and many others well known to surgeons, and scTcral additional
ones recorded by members of the profession in this ci^, to which
I shall have occasion to refer in another place, — all prove the iatal
nature of many of these aural affections, — they certainly do Bd
establish the theory *< that each of the cavities of the ear haa its
particular division of the encephalon to which it communicates
disease.**

CUTANEOUS DISEASES OF THE MEATUS.

Diseases of the skin, particularly herpetic and eezematoue enep^
tions, extend from the auricle into the meatus; or thej may be
seated in the latter alone. In either case the treatment is similar.
If allowed to proceed unchecked, they produce thickening of the
lining of the passage, lessening its caliber, and in time steal over
the external layer of the membrana tympani. As the result of
chronic inflammation, the lining of the meatus becomes thickenedf
and may sometimes be peeled off like the detached cuticle of a
blister or bum upon any of the exposed surfaces of the body.
There is a thick pasty matter, not unlike the softened cuticle which
may be scraped from the soles of the feet, sometimes coating over
the passage: and occasionally the whole thimble-like cuticular
lining of the meatus comes out eti fnasse. In all these cutaneous
affections, in addition to the treatment already referred to when
they are seated in the auricle, great benefit will be derived fiom
the application of a solution of nitrate of silver, — ten grains to
the ounce ; and subsequently, when the lining has become more
healthy, the use of the citrine ointment, referred to at page 171.
Bell, in his work on Lues, speaks of deafness produced by a **9CTuffj
eruption,"" and sometimes ulceration of the external auditory pas-
sage, occurring as a consequence of that disease ; but his descrip-

CUTANEOUS DISEASES OF THE BXTE&HAI. CANAL. 199

don is not sufficiently accurate to be depended upon, and has not
been confirmed by subsequent observers. No doubt, cutaneous
syphilitic disease will extend by ordinary continuity of surface
into the meatus, but as a special form I am unacquainted with it.

I have seen cases of intolerable itching of the mealus^ with a
dry branny state of the cuticle, lasting for months, and giving rise
to heat and redness of the auricle. Paroxysms of the disease come
on at stated periods, generally in the evening. Cases of this na-
ture, and all other diseases of the meatus, attended by extreme
dryness and an unhealthy state of the cerumenous secretion, will
be benefited by the application of glycerine, and some by the solu-
tion of gutta percha in chloroform.

The amount of hair growing round the meatus and attached
to the posterior surface of the tragus is very various. Sometimes,
particularly in persons from fifty to sixty years of age, the vibriescB
fall out, and resting either on the meatus or membrana tympani,
cause intense annoyance, and at times produce increased redness
of the lining of the passage. Syringing affords but little relief,
for the wet hairs only adhere to the parts more intimately. The
meatus must be carefully inspected with the speculum under strong
sunlight, and each hair gently removed with a long fine forceps.
It requires some delicacy of manipulation to lift a hair from off
the membrana tympani without giving the patient pain; but it is
the only effectual remedy.

Ulceration of the meatus is of itself a rare disease ; but it is a
frequent concomitant of other affections, such as otorrhoBa, or the
irritation of substances introduced either by accident or for cura-
tive purposes. It often attends chronic erysipelas, and- also condy«
lomatous growths at the orifice of the canal. Extreme cleanliness,
mild astringent washes, the application of nitrate of silver, toge-
ther with the constitutional treatment recommended at page 170,
will generally cure cases of this description.

MORBID GBOWTHS AND ALTERATIONS IN THE EXTERNAL AUDITORY

CANAL.

Variations from the normal caliber of the external meatus may
arise from a number of causes, — viz., collapse of the flexible por-

200 CL08UBB OF THB XXTBBVAL HIATUS.

tion of its walk, of which an example is gi^en below; or the ob-
▼erse state, in which the external aperture is pretematurally wide
— a common consequence of long-continued otorrhoea; strictoiet
either congenital or acquired, in its middle part, and alao morbid
growths, such as polypous, bony, or other tumours.

No. 20 in the Registry is a case of domire of the extenud mso-
tu8; in T. S., a female, aged 54, who says she became deaf gra*
dually during the last three or four years. Has tinnitus anriam;
but no pain or soreness in the ear. There is little to be learned
from the history of this case ; but a glance at the ezlemal ear
affords a tolerably good idea of the cause. Upon looking at the
meatus we perceive that it has lost its usual OToid shape, and
has become a mere elongated slit or fissure marked by a dark
line where the incunrated edges are in contact Upon drawing
forward the tragus, we rather increase the defect, but by grasp-
ing the auricle immediately above the anti-tragus, and drawing
it outwards and a little forward, we can to a certain extent restore
to its natural size and posidon the external auditory aperture.
The hollow formed between the tragus and the external meatus
is much larger and shallower than natural ; and on pressing with
the finger in front of the tragus and beneath the sygonu^ where
the skin is rather corrugated, we are unable to push the tragus
backwards into the concha so as to cover the meatus extemus, to
which in normal cases it ought to act as a sort of operculum*
Upon examination with the speculum, we find the flexible walls
of the auditory tube compressed, the lining of the passage white,
and its cuticular investiture thickened as if by maceration, and
detached in patches, while a slight, whitish, curdy discharge col-
lects round the edge of the tubular speculum. The tympanal
membrane is white, and apparently thickened. There is no evi-
dence of cerumenous secretion in any portion of the passage.

Upon enlarging the external meatus, either by the means first
pointed out, or by the introduction of the speculum, the hearing
is increased. She can now perceive the ticking of the watch at
six inches; previously she only heard it when pressed against the
auricle.

Closure of the external meatus may arise from a variety of

CLOBUBB OF THB EZTEBVAL MBATU8. 201

causes, of which I possess examples in an extensive series of
drawings. In the instance detailed, it does not seem to be the
result of any inflammatory process, but appears to have been
caused by some force gradually exerted upon the tragus, drawing
its point forward toward the cheek, and pressing its base back-
wards,— ^possibly permanent spasm of the tragicus muscle. It is
a very slow and gradual process, and is, therefore, seldom attended
to by the patient until complete closure of the meatus ensues.
The deficiency of cerumen, the thickened cuticle, and the slight
discharge observed in the passage, are the result, not of the origi-
nal disease, but the subsequent closure and pressure of the sides
against each other. It is a disease of middle or advanced age;
and although it attacks one ear first, it generally appears in that
on the opposite side. It is most difiicult to manage. I have had
thoughts of making an incision in front of the tragus, so as com-
pletely to divide any muscular fibres which might have produced
the deformity ; but I fear that plan would not be attended with
much success, for I have, from long experience, remarked that
when once any of the free cartilages, as the eyelids, nose, or au-
ricle, become viciously bent or distorted from their natural posi-
tion or curvature, that it is almost impossible to restore them by
any effort of art. I have used tents made of compressed sponge
for the purpose of gradual dilatation, but I cannot say that I have
effected much thereby ; they should, however, be given a fair trial
in every case. The canal ought to be cleansed firom those impu-
rities which collect therein, and the parts washed over with a
strong solution of nitrate of silver, and a fresh tent should be in-
troduced every night, and removed in the morning. With intel-
ligent persons, in the upper ranks of life, this plan of treatment,
if proceeded with for a sufficiently long time, will be attended
with benefit; but with careless, stupid people, among the lower
orders, who pay little attention to cleanliness, it has but a slight
chance of success. Defective hearing arising from this appa-
rently mechanical cause is one of the few diseases that may be
relieved by the introduction of a small metallic tube shaped like
a wine-funnel. We see those constantly advertised as a means
of relieving every description of deafness. I need not say that,

iOi C|iO0UBB OV THB SZTIEHAL MXATUS.

from the rarity of the peculiar diBoase to which thej are i^plica-
ble, how very few caaes they can afford relief to. A£» howevery
they are silver-gilt, are sold in very neat morocco caaea, and cost
a guinea, they serve the purposes for which they are advertised:
they do not cure ; they only sell. Baron Larrey, the inventor of
these tubes, supposed that the disease which they are intended
to remedy was caused by loss of the molar teeth of one or other
maxilla in early life, when he says there results a ** gradual dis*
placement, upwards and backwards, of the condyles of the lower
jaw-bone, which sink into the glenoid cavities of the tempwal
bones so as to become lodged at the bottom of the articular cavi-
ties, beyond the Glasserian fissure, and before the meatus extemos^
the parietes of which will then be depressed in the same direction ;
the auditory passage i^gradually obliterated, or undergoes such
an alteration that the rays of sound can no longer reach the tym-
panum, from whence results deafness." I have seen cases of this
disease, however, in which the molars had not been lost.

Several years ago I had under my care a case of this descrip-
tion, in a very intelligent old gentleman, and having made an ac-
curate wax cast of the concha and meatus, while the latter was
drawn open, as already described, Mr. Grimshaw made for him
a silver tube, which, fitting accurately to the parts, gave no in-
convenience, was not remarkable, and very much improved the
hearing. Pads have been constructed to fit behind the ear, and
press the auricle forwards, but they do not afford the desired relief.
Persons who are aware of this cause of their deafness do not, when
conversing, place the half-closed hand behind the auricle, in order
to collect sound, but very soon learn how to enlarge the meatus^
by drawing the auricle outwards and a little backwards.

In ordinary cases of otorrhoea, particularly where the discharge
is profuse, the meatus is often rather larger than natural, and the
excoriations, which sometimes occur where the matter is of an
ichorous character, being always more or less moist, and not form-
ing crusts and scabs, do not produce any contraction of the exter-
nal aperture ; but other cases present where the meatus is closed
by morbid growths, of which the following instance is an ex-
ample.

COHDILOMA OF THB EXTEBHAL MEATUS. 203

Condyloma of the external meatus is a rare form of disease.
M. D. L. (No. 21 in Registry ), a female, aged 25, saffers from
deafness, tinnitus, occasional pain, foetid and sometimes bloody
discharge from left ear, for eight months ; is otherwise healthy ;
attributes her affection to cold. The external meatus is completely
closed by several condylomata which grow around its margin, but
particularly from its lower edge. They are rather sensiuve to
tbe touch, lobulated on their surface, project a considerable dis-
tance beyond the margin of the aperture, and are a little more
florid in colour than the natural skin. When the tragus is pressed
backwards with the 6nger, a muco-purulent offensive discharge
exudes between these growths. It is not possible to insert even a
small-sized speculum into the meatus without causing great pain
and irritation. She can only hear the watch on touching. The
right ear is normal. The excrescences were touched with solid
nitrate of silver, after which a poultice was applied. The subse-
quent treatment consisted in washing over the morbid growths
with a strong solution of nitrate of silver every second or third
day, and, in the intermediate time, keeping a dossil of fine lint,
wet with diluted liquor plumbi, applied to the concha ; besides
the internal administration of Plummer*s pill and sarsaparilla. By
persisting in this treatment for upwards of two months, the condy-
lomata disappeared, leaving the meatus natural, when the mem-
brana tympani was found unimpaired, and the hearing was restored.

The following case, No. 24 in the Registry, presented an un-
common form of tumour in the meatus: —

M. N., a female, aged 47, has been deaf of the right ear for
many years, and is much annoyed by itching and a stuffed feeling
in the meatus. A tumour, in shape, size, and colour resembling
a half-ripe mulberry, occupies the anterior and lower edge of the
meatus, and extends some way into the auditory tube, which it
almost completely blocks up. It is not unlike that disease known
here as *' button scurvy," and to which the late Dr. Wallace of this
city gave the name o( morula. It is attached by its broad base
throughout its whole extent, and has neither enlarged nor ex-
tended for the last five years, during which time I have been in the
habit of examining it occasionally. The patient never had otor-

204 8Z0fTO8I8 or XHB SZTBBVAL MBATUl.

rhoea; and there is no discharge now present, but at times the
tumour becomes painful and irritable^ and then its colour deep^is
from a florid red to a purple. It is of a firm consistence, corru-
gated on its surface, and has an unyielding feel, quite unlike a
nasvus, for which at first sight it might be mistaken. I have not
meddled with this tumour, as I once saw, and have described at
page 206, an affection somewhat similar in external appearanoei
in a lady about this woman's time of life, end in malignant disease,
apparently hastened by treatment.

We meet with various other growths in the external meatus
and auditory tube, independent of polypus or other morbid pro-
ducts, resulting from inflammation or its consequences. One of
the most frequent of these is esodatUt of which I have seen very
many examples. The projection generally grows from the poste-
rior edge of the osseous portion of the tube, and slowly, but gia*
dually, projects forwards, so as to leave but a slight crescent-shaped
fissure between it and the anterior wall of the meatus. The inte-
guments covering such growths are generally very smooth, white,
and polished. I have seldom seen this disease affect both ears, but
I have often remarked it in connexion with inflammatory aflbe-
tions both of the external tube and the membrana tympani. An*
tenrieth has given an account of one of these growths ; and in 1849
Mr. Toynbee communicated a valuable paper on the subject to the
Provincial Medical and Surgical Journal, giving an account of
twelve cases. That paper is illustrated with woodcuts represent-
ing views and sections of a portion of the temporal bone in a dry
state, exhibiting in particular the mastoid process, and a section
of the bony meatus, in order to show the position of the encroach-
ments made by these morbid growths. I do not think it at all un-
likely that the temporal bones of the various persons alluded to
in Mr. Toynbee*8 paper may, after death, present the appearances
which he has delineated : and the diagrams showing the form of the
meatus, and the amount of bony growth therein, are, no doubt, per^
fectly allowable : but I am not so well satisfied with illustrations of
any kind except such as are absolutely drawn from nature. The
treatment recommended for these growths is the appUeation of
iodine : when, however, the disease has advanced to any extent, I

BX0BT08I8 or THB SZTBBVAL M8ATU8. 205

haTe not much faith in any remedy ; but in the early stage^ when
the exostosis is probably the result of chronic periostitis, local de-
pletion, counter-irritation, and mercurials, will arrest its progress.
Fortunately, these little bony nodules, which very much resemble
the excrescences which grow from the beech tree, are usually of
very slow growth. I know one which has not, apparently, in-
creased during the last eight years. On the contrary, I may men-
tion having just seen a case, in consultation with Dr. Morgan, in
a gentleman who asserts that he heard quite well with both ears
twelve months since ; he then began to lose the hearing of the
right, which is now quite gone. A few months ago the left was
nmilarly attacked, and he can only hear with that ear by insert-
ing the finger for some distance into the concha, and forcibly
drawing the tragus downwards. Being much occupied with bu-
siness, he paid no attention to his disease ; at least he sought no
adyice for it until the past week. Tet this is a gentleman, I am
told, of considerable professional acquirements, and conducting an
extensive business. It seems almost incredible with what apathy
and indifference men reputedly clever will permit their hearing to
be lost without making any effort for its restoration. But, although
they have allowed the day of grace to pass by, many of them are
not slow in enlightening society upon the subject of the impossi-
sibili^ of curing deafness, or their complete want of faith in me-
dicine. In the case of Mr. B., just alluded to, the external meatus
on the right side is completely closed by a hard, smooth exostosis
growing from its posterior bony wall, and filUng up the canal so
perfectly that no vestige of it can be seen except a crescentic line
where the new growth meets the anterior wall. He cannot hear
the watch even when pressed against the auricle. * The progress
of the disease has not been attended with pain, and the gentleman
is in perfect bodily health. Upon the left side he can hear the
watch when pressed against the auricle, there being, fortunately
for the patient, two exostoses, which, meeting by their convex sur-
fiu^es, have prevented complete closure of the inferior portion of
the meatus, and as there are still manifestations of inflammatory
action going forward in the meatus, treatment holds out a hope of
improvement. (See page 209.)

206 XALIGMAVT DI8BA8B OP THB MUTUS.

Schmalz has figured a small exostosis from the work of Plater-
nus, which grew within the vestibule; and several instances have
been recorded of exostoses within the cavity of the tympanum.

When otorrhoea has been long established, or that caries has
taken flacet fiUulaua opentng$ form between the external meatus
and the mastoid or aural regions. In the former situation they are
not at all uncommon ; I have, in two instances, seen sinuses five
inches in length, extending from the external auditory canal along
the side of the neck, and not long since there was a patient at the
Hospital labouring under phthisis and otorrhoda, who could pump
the matter out of his ear by pressing upon an abscess situated over
the upper edge of the scapula.

Polypi in the external meatus are very common, and gene*
rally grow from some part of the bony portion of the canal. As
they are always attended with otorrhcsa, they shall be considered
in the chapter devoted to that subject. The consideration of m-
ries also belongs to the chapter upon otorrlioea.

MAUGNANT DISEASES OF THB MEATUS.

Malignant diseases in the external meatus are very rare, al-
though they may engage that part in some stage of their progress.
Of lupoid ulcerations, and cutaneous cancer, I have already spoken
at page 172. Osteosarcoma of the lower jaw or the malar bone
sometimes encroaches upon the meatus, as may be seen in the mor-
bid specimens in our museums. The following case is worthy the
attention of the surgeon, as it shows us how careful we should be
in meddling with morbid growths of long standing, without being
fully satisfied as to their nature and the place from which they
grow.

A female, aged about 50, whose brother I subsequently heard
had died of cancer, consulted roe some years ago on account of a
polypous growth in the right ear, attended with a remarkably fe-
tid discharge of many years' duration. She had an unhealthy look,
and complained occasionally of giddiness, loss of rest, and sick-
ness of stomach. The otorrhoea having increased considerably of
late, she was anxious to have it removed if possible. The meatus
was filled with a large reddish-brown flabby polypus, much darker

MALIOVANT DI8BA8B OF THB MBATU8. 207

in colour than I had ever seen before. On examination I found
it firmly attached to the lower and posterior wall of the external
meatus, and I could not lift it up or pass a probe round it, as can
generally be effected in ordinary cases of polypus, no matter of
how long standing. Neither did it present the circular protube*
ranee which forms in cases of fibrous polypus as soon as the mor-
bid growth has cleared the meatus and commenced to mould itself
into the shape of the external aperture. It was not possible to
examine the canal, so completely did the morbid growth fill it up,
bat a probe could be passed with facility all round its upper and
anterior surface. These were the only symptoms which presented
when I first saw her. She stated that she had latterly suffered
firom pain in the ear, and that upon several occasions during the
past year pieces of the polypus had come away. Finding it im-
poesible to pass a snare round it, I removed a portion of it with a
aoissors, and the hsBmorrhagc which followed was inconsiderable.
Subsequently I attempted to lessen the growth by the application
of nitrate of silver applied to its surface, and also by passing a small
sharp-pointed probe, coated with the caustic, through its surface.
Constitutional treatment calculated to improve the patient's health
was not neglected ; and for a short time, the local appearances
improved, but I was never able to clear the meatus of the morbid
growth. My attention was soon attracted by the rapid progress of
the fungoid mass, which increased almost as quickly as it was re-
moved. In the course of a month the serious nature of the disease
manifested itself The growth from the meatus assumed a livid
unhealthy colour. The auricle was pressed forward and outward
by a fluctuating tumour over the mastoid process. This I opened,
and a quantity of dark-coloured foetid matter was evacuated, and
considerable relief experienced for a short time. Paralysis of that
side of the face next appeared ; several large abscesses formed along
the course of the mastoid muscle; well-marked rigors ensued, and
ike general health gave way, the characters of malignant disease
being strongly marked in the countenance. Convulsions, followed
by long fits of coma, ensued, and the pain at times was most excru-
ciating. The post-aural and infra-aural regions rapidly enlarged ;
the integuments of the mastoid region gave way, and a large

208 MAUQVXST DI8BA8B OF THS MBATUS.

fungoid mats sprouted theie&om, which, in a few days, attained
the size of a lemon. The footor was the most intolerable and ack-
ening I ever smelled, and death put an end to her sufferings in
about three weeks after the external appearance of the fungus,
which presented all the characters of true malignant disease. I
was unable to obtain a post-mortem examination.

Whether benign disease can, by interference, be converted
into malignant, has not yet been decided by pathologists. Where
the disease originated in this case, it is not possible to determine;
eventually, however, it must have engaged all the cavities and
structures of the ear. The only point in which this case differed
from one of ordinary polypus, resulting from chronic inflammation
and otorrhoea, when I first saw it, was in the attachment of the
growth to the external and posterior lip of the meatus.

The following case, for the particulars of which I am indebted
to Mr. Ciisack, occurred in this city in 1843. It was originally
published in my essay on otorrhoea, but is so similar in many re-
spects to the foregoing that I insert it here.

An apparently healthy boy, seven years of age, was brought
to him on account of a discharge from the external meatus. Upon
examination, a small polypus was discovered in the passage; this
was removed, but on the third day following it was found to have
grown as large as ever ; it was again repeatedly removed, and the
usual slightly astringent washes were had recourse to in the inte-
rim. This polypus or fungous growth did not present anything
remarkable except the extraordinary power of being reproduced
in a day or two, on which account it was no longer attempted
to be destroyed, but a more palliative mode of treatment was had
recourse to. Not long after, the child was suddenly seized with
an epileptic fit ; and then, on closely examining the ear, a fluctu-
ating point was discovered over the mastoid process; this was
instantly cut down upon, and the opening gave exit to a laige
discharge of pus. It was then found that the cavity which con-
tained this matter communicated by a fistulous opening with the
external auditory tube ; — a fungous mass almost immediately
sprouted through the incision ; the parts in front and all round the
ear became swollen, and had that peculiar boggy keX to the touch,

MALIGNANT DISEASES OF THE MEATUS. 209

which left but little doubt regarding the malignant nature of the
disease. The original aural polypus remained as before, but, from
the struggles of the child and the condition of the parts, at no
one period was it possible to learn with accuracy the state of the
tympanum. Repeated attacks of epilepsy, each increasing in vio-
lence, and the intervals shortening in duration, followed quick
upon this deplorable condition, and death soon closed the scene.

Upon examination it was discovered to be a well-marked case
of osteosarcoma of the petrous and mastoid portions of the tem-
poral bone. The petrous portion in particular was enormously
enlarged, and so softened as to be capable of being cut with a
knife. The whole presented a large fungous mass, which, how-
ever, did not engage that portion of the brain which lay upon it.
All traces of the internal ear had been obliterated. There can, I
think, be little doubt, but that in this case the original disease
was seated in the bone, and that the aural discharge and fungus
were but secondary morbid appearances.

Dr. Hutton has just informed me that he had lately under his
care a case of chimney-sweepers' cancer of the external ear.

A fortnight after the note of Dr. Morgan's case of exostosis,
referred to at page 205, I saw Mr. B., whose treatment had, in the
interim, consisted in leeching the meatus, and the internal admi-
nistration of minute doses of the bichloride of mercury. The im-
provement was truly astonishing : the protuberances in the left
ear had lessened considerably, and the hearing was nearly restored
on that side.

We sometimes meet with small, white, round bodies, the size
of millet seeds, in the walls of the meatus, similar to those frequently
seen about the eyelids.

In describing the diseases of the auricle, I should have men-
tioned ** dislocation," of which a remarkable example presented at
South Carolina, in which the auricle was detached from its seat,
and carried downwards on the surface of an enormous pendulous
tumour. (See London Medical Repository, 1816.)

210

CHAPTER V.

DISEASES OF THE MEMBRANA TTMPANI.

Anatomy of Membrana Tympani. — Its Congenital Malformations. — Injuries of: Rap-
ture. — Inflammations : Acute ; Rheumatic Otitis. — Subacute : Syphilitic ; Gouty. —
Senile Deafness. — Strumous ; with Ophthalmia. — Exanthematous ; Typhoid. — Chro-
nic Thickening and Morbid Deposits in Membrane. — Cutaneous Diseases. — Collapse,
with Loss of Vibration Operation of Perforation Ulceration ; Apertures in Mem-
brane; Total Destmction oC — Artificial Membrana TympanL

THE memhrana tympanic or drum-head, separates the external
meatus, at the extremity of which it is placed, from the ca-
vity of the tympanum ; so that, from its position as well as the
anatomical connexion of its structures, it must partake of the
diseases of both cavities independent of those peculiar to itself. It
is a thin, semitransparent, dry membrane, of an irregular oval
shape, varying in size as much as the cornea, but generally mea-
suring about eight-twentieths of an inch in its longest diameter,
which is in a diagonal line from above forwards and downwards.
It is placed obliquely from above downwards, and somewhat
from before backwards and outwards, and set in a well-marked
groove upon an elevated ridge, at the tympanal margin of the
bony meatus, like the crystal on the besil of a watch. In foetal
life this tympanic ring is a separate and distinct portion of the
temporal bone, and does not become altogether incorporated
with it until some time after birth. It is produced from a sepa*
rate and distinct point of ossification, and may, therefore, be re-
garded as a fourth division of the temporal bone superadded to
those already enumerated at page 150. From this ring grows the
osseus meatus auditorius externally, and also a portion of the floor
of the cavity of the tympanum internally. This circle is never
completed, as may be seen by examining a section of the tempo-
ral bone, made through the tympanum, immediately behind the
groove for the attachment of the membrane. It remains deficient
superiorly, where the malleus joins the memhrana tympani, and

ANATOMY OF THE MEMBBANA TYMPANI. 211

at which point the head of that bone lies in the superior sinus of
the tympanum. If we examine a number of temporal bones, we
will find the groove for the meuibrane deepest at the lower and
back part, and least marked above, towards the part where the
ring is generally deficient.

The manubrium, or handle of tlie malleus, is enclosed for about
three-iburths of its length between the laminae of the mcmbrana
tympani, which are partially inserted into it. This process of the
hammer-bone serves to support and also to preserve the peculiar
carvature of the membrane, as well as to convey to tlie hibyrinth
the vibrations of sound which impinge upon it. At birth the tym-
panic ring, with its enclosed membrane, looks obliquely downwards
and slightly outwards, and it is only by the formation of the floor
of the tympanum that the position which it assumes in adult life
is produced. The membrana tympani is also proportionally larger
in the fostus than in the adult. A knowledge of these relations is
important in a pathological point of view, as they show how easily
disease of the meatus or the membrana tympani may be propagated
to the neighbouring parts.

Viewed through the speculum, with a stream of clear, direct
sunlight upon it, the membrana tympani is of a greyish hue, and
semi transparent consistence ; and presents externally an irregu-
larly curved surface, as also difierent degrees of density, polish,
and tension. It is divided by a white streak, thick above and nar-
row below, except at its extremity, which is slightly enlarged and
indented into a navel-like depression. This white opaque line is
the manubrium of the malleus, proceeding from the upper attach-
ment of the membrane downwards, somewhat backwards and a
little inwards to a point slightly below the centre of the mem-
brane, and thus divides it into an anterior, a posterior, and an infe-
rior portion. But the exact situation of this bone, and consequently
the relative proportions of the parts which it divides, present great
diversity. The anterior part of the membrane is thin, — almost
transparent, or as clear as fine gold-beater's skin, — highly polished,
and generally convex — a speck of bright light being reflected from
its most prominent part. This may be called the anterior vibrat-

q2

212 AVATOMT OF THB MEMBRANA TTMPANI.

ing portion. In many cases the short process of the malleus may
be seen as a small round dot above the manubrium where the mem-
brane curves oflf into the roof of the meatus. The bottom of the
meatus, it should be remembered, is funnel-shaped, the broad end
of the funnel being towards the tympanum.

When the centre of the membrane is under examination, its an-
terior attachment, behind the sharp curve of the meatus, cannot
at the same time be seen, nor until the tubular speculum is turned
towards it, and the head of the person examined is brought into
the proper angle ; and the same remark holds good, except in cases
of very large meatus, with respect to the posterior margin ; the
superior and inferior attachments are more easily observed; but,
by rotating the speculum, and altering the head from side to side,
we can bring in succession each portion of the membrane into
view. The relative size of each portion of the membrane varies
in different individuab. In making this examination the tube
should not be inserted much beyond the middle of the mea-
tus. Below and behind the malleus the membrane is also thin,
clear, and glistening, but not quite so diaphanous. Beneath
the point of the malleus it is flaty and behind it rather concave^
but not always so. These portions do not usually present in
their normal state spots of reflected light. Superiorly, from about
the upper half of the malleus, the membrane becomes gradu-
ally denser until it is quite white ; it also forms concave curves
from the upper part of the malleus, the posterior one being deepest
and whitest. Above, the membrane forms a gradually vaulted
curve into the roof of the external auditory canal, with the lin-
ing of which it is imperceptibly blended ; while in front, below
and partly behind, there is a sharp, well-defined line of demarca-
tion between it and the meatus, and sometimes a slight, whitish
thickening, which in disease and in some old persons resembles
the arcus senilis, except that in the cornea there is always a nar-
row clear space between the opacity and the sclerotic. In some
persons there is a slight purse-like projection of the membrane
near its upper attachment and behind the tubercle of the malleus
— the "mcmbrana fiaccida** of Sharpnell — rudimentary in man.

AirATOMT OF THE MBMBBAHA TTMPAVI. 213

but well developed in some of the lower animals. The speck of
light which is generally reflected from the most convex and pro-
minent portion of the membrane is not always in the centre of the
anterior part, but is often seen beneath it. If a horizontal section
of the membrana tympani be made, it will present somewhat the
form of an italic ( /*), the middle point being the circular flattened
extremity of the manubrium of the malleus.

If the patient under examination inflates the tympanum after
the manner described at page 64, without moving the head, alter-
ing the position of the speculum, or in any way deranging the
light, the whole of the anterior and part of the lower portion of
the membrana tympani is bulged outwards, and the speck of light
appears as if spread over a larger surface, or is entirely lost for the
moment. Whether the membrane is then rendered more or less
tense I cannot satisfactorily state. In some cases a slight eleva-
tion or outward pressure of the malleus, and even of the whole
membrane, may be observed. If the inflation be continued, the
upper white portion frequently becomes red, and vessels can be
seen at times spreading from it along the sides of the malleus.

Cheat diversity of opinion exists among authors with respect
to the curvature and general appearance of the healthy membrana
tympani. They almost all, however, agree in pronouncing it a
uniform concavity ; but this I believe to be a post-mortem appear-
ance. One of the proofs aflforded by anatomists of the external
concavity of membrana tympani is, — that, when the cuticular lin-
ing common to it and the meatus is removed entire, and floated in
water, its extremity forms a curved pouch like the finger of a
glove. This, however, is a very fallacious test ; for, if we take
the finger of a glove and invert its extremity, so as to present a
marked convexity towards its internal surface, wc can easily,
either by blowing into it or drawing it through water, make it
assume a concave appearance.

Well acquainted as every person familiar with the character
which the membrana tympani presents upon inflation, it will ap-
pear almost incredible that Dr. Kramer should believe that even
a forcible stream of air from the air-press cannot alter its concave
form.

214 ANATOMY OF THE MEMBRANA TTMPANI.

It is of great importance that we should be not only acquainted
but familiar with, the external appearance of the membrana tym-
pani in anormal condition ; yet how many practitioners pass through
life without ever having seen it in the living state ! — all they know
of it being from description or preparations shown them during
their anatomical studies.*

Behind the attachment of the membrane superiorly, there is
the head of the malleus, which rises above it into a large hollow
in the bone, which freely communicates with the mastoid cells.
Anteriorly, and somewhat below the middle line, there is the
tympanic opening of the Eustachian tube, opposite the portion
of membrane most easily acted upon by a stream of air, and that
where it most usually gives way. Below and behind the Eusta-
chian tube is the carotid canal, usually perforated in that part
of its posterior curve nearest to the membrana tympani by a small
aperture for the transit of a vessel which, being distributed to the
membrana tympani from so near and large a stream, may, with
its other plentiful supply, account for the pulsation which that
membrane presents in certain forms of disease. Behind, and
winding round its posterior and upper margin, the aqueduct of
Fallopius conducts the portio dura to the stylo-mastoid foramen ;
and the proximity of that nerve to the cavitas tympani and its
external partition, will enable us to account for the facial paralysis
which frequently accompanies disease of the ear.

The structure of the membrana tympani has been carefully in-
vestigated by many eminent anatomists, and is found to consist of
a proper fibrous layer, and two others borrowed from the neigh-
bouring structures, — viz., the epidermis continuous with that re-
flected over the meatus externally, and the fine, delicate, mucous
lining of the tympanal cavity — a portion of the great gastro-pul-
monary investiture prolonged through the Eustachian tube — inter-
nally. The tegumentary or external cuticular layer is, in a healthy
condition, remarkably fine, and so transparent that the fibres of
the layer beneath it can be seen distinctly through it ; yet, in dis-

* In addition to Uie fore^ing observations, see the remarks upon the membrana tym-
pani, at pp. 10f)-7. See also the author's description of this structure in the Dublin
Quarterly Journal of Medical Science, vol xxiv. p. 421. 1844.

AHATOMT OF THB MEHBRAXA TYMPANI. 215

or by decomposition, it is rendered white and thick, and can
frequently be detached in an unbroken scale. Within, the mucous
linii^g is so fine that it is discerned with difEcuIty, yet in disease
it becomes thickened, vascular, villous, and even pulpy.

The middle or proper fibrous layer is composed of two lamina:,
— a radiate externally, a circular internally ; in addition to which
there is a cartilaginous or ligamentous ring, already referred to at
page 213, which is somewhat denser and whiter than the rest of
the membrane, and surrounds its attachment, except at the upper
portion where the osseous groove, into which it is inserted, is de-
ficient. This cartilaginous circle is continuous with, and inti-
mately united with the periosteum, and the radiating fibres of the
external layer are inserted into it. In the living, healthy car, it
can often be distinguished from the rest of tlie membrane, but in
disease it becomes very manifest, and frequently presents a bnght
vascular zone, when the rest of the membrane is unaffected. It
is also the seat of that inferior crescentic opacity described in the
analysis of the Registry, at page 136. The fibres of the external
radiating lamina proceed from the sides and the extremity of the
malleus to the cartilaginous ring for about the inferior half of the
membrane. Superiorly the fibres pass across or are external to
the upper portion of the malleus, and are inserted into the perios-
teum of the meatus. The circular lamina passes, for the most part,
behind the handle of the malleus, and is united by fine cellular
tissue to the radiating layer in front of it. It is unconnected with
the cartilaginous ring, but is said to be continuous with the pe-
riosteal lining of the tympanal cavity.*

* Mr. Toynbee, the latest autiiority upon the subject, has, in an Appendix to his pa-
per "On the Membrana Tj'mpani of the Human Ear," in the Philosophical Transactions for
1851, described the membrana tympani as composed of six laminae, — viz., the epidermoid,
or coticular; the dermoid, a distinct and complete lamina of membrane which is oonti-
naoQS wiUi the dermoid layer of the meatus, and which, from its containing numerous
blood-vessels, might be called the vascular layer ; the external radiating lamina of the
fibrous layer, continuous with the periosteum of the meatus ; the internal circular, conti-
nuous with that of the tympanum ; the mucous lining; and finally the epithelium cover-
ing that structure, in addition to the circular fibro-cartilagiuous portion already described.
But these are too minute subdivisions for practical purposes.

iia ANATOHT OF THE H8HBBANA TTHPAKI.

Sir Everard Home and others maintained that the membntna
tympani was muscular, but Bubeequent observers have not con-
finned that idea ; and ProfeBsor Harriaon, in his dissection of the
ear of an elephant, that died some years ago in the Zoological
Giardens,is of opinion that the membrane is not muscular. Rivinus,
and some of the older anatomists, conceived that a natural aperture
existed in the membrana tympani, but thiaerrorhas been corrected
by modem investigation. That many persons have, however, a
perforate membrana tympan! without experiencing any inconvc*
aience from it, is well known; such persons are generally able to
force tobacco smoke through the external meatus. The thinnest
portions of the membrane are about midway between the points
of the malleus downwards and forwards in the anterior portion,
and downwards and backwards in the posterior portion. It is,
therefore, in one or other of these spots that we generally find it
perforated by either accident or disease.

The membrana tympani is, in a state of health, highly sensitive,
the slightest touch producing the most acute pain. Mr. Wharton
Jones says it receives " a nerve from the third division of the
fifth, which has communications with filaments from the chorda
tympani."

Thin, dry, and almost transparent as the membrana tympani
appears in the healthy living state, it can, by fine injection, be
rendered a complete vascular net-work, and the same appearance
may b« perceived in disease, modified according to tlie peculiar
structure or special vessels engaged. Arnold,
in his magnificent lithographic plates, has
given figures of the veins and arteries of the
membrana tympani, from the latter of which 1
I have had the accompanying accurate wood-
engraving copied." Soemmerring has also
faithfully represented the arteries of the tym-
panal membrane in the normal condition as
two long vessels proceeding from above downwards and backwards

• TibDlK AnmUmicm; FsBcii-uliu Secondn*; T«b. v., fig. 38. The Dnvtng, re-
ducal •bmrt one-third, hu been copKd utd engravn) with great fldditr by Mr. Ohlbun.

AHATOMT OF THE MEMBRANA TTMPANI. 217

along the course of the handle of the hammer, and branching on
either side into the anterior and posterior vibrating thin portions
of the membrane. The outer circle in the woodcut is the bony
ring upon the right side seen from within in an infant, and the
central body is the cut off extremity of the manubrium. The
large artery proceeding from above downwards is the tympanic
branch of the stylo-mastoid, which anastomoses freely and by
large trunks at the upper deficiency of the ring, with vessels re-
ceived from the internal maxillary through the Glasserian fissure.
These vessels, uniting, send a considerable trunk along the attach-
ment of the manubrium ; but in the living state, when the mem-
brane is irritated, two or three vessels can generally be seen
coursing downwards on each side of the bone, and looping round
its extremity. This tympanic artery then radiates, as shown in
the cut, towards the periphery of the membrane, where it inoscu-
lates so freely as to form a circumferential vascular plexus with
the tympanic branch of the deep auricular which is given off at
the angle between the temporal and internal maxillary. This
latter vessel reaches the membrane at its lower curvature, and
forms that crescentic red appearance frequently seen in partial
inflammation of the lower portion of the membrana tympani.
Both these vessels ramify on the external surface of the proper
fibrous layer, and being continuous with the vascular supply of the
external meatus and the auricle, show how much more effectual
local depletion made round the aperture of the auditory canal
must be in relieving turgescence of the vessels of the membrana
tympani than when applied on the mastoid process, as formerly in
use. Towards the upper portion, in particular, we can frequently
trace those vessels which ramify about the malleus into the vaulted
roof of the meatus.

That the mucous lining of the tympanic cavity, reflected over
the back of the membrana tympani, though so thin and transpa-
rent in health as to be demonstrated with difficulty, becomes in
disease suddenly and intensely vascular, I have had maiiy oppor-
tunities of determining. In such cases, the proper fibrous layer,
as well as the cuticular envelope of the membrana tympani re-
main polished and as transparent as natural, while the inflamed

218 ASATOMY OF THE MEMBRAMA TTMPAKI.

mucous lining may be seen through these structures of a pinkish
colour, somewhat like that observed on the under surface of a
monthly rose-leaf The arterial supply of this lamina is obtained
from a variety of sources, viz., the stylo-mastoid, the temporal,
the internal maxillary, the meningeal, and the internal carotid
arteries ; the latter sends its twig through the small hole in its
bony canal, referred to at page 214. When the proper fibrous
membrane is inflamed, it will sometimes present one uniform sheet
of bright red ; in addition to which I have frequently seen and
pointed out to my pupils several small straight vessels superficial
to the general redness, and radiating from the centre towards the
circumference.*

During life these vascular arrangements can only be seen in
disease, and with a stream of clear bright sunlight directed upon
the membrana tympani. Having brought the membrane fairly
within the field of the speculum, a magnifying glass held in the
proper position will not only, by enlarging the parts under inspec-
tion, but also by concentrating the light upon them, materially
assist our view. I lately showed, that when the membrana tym-
pani has been perforated, the globule of air, or mucous bubble,
entangled in the aperture pulsates synchronously with the heart
and arteries.l That this motion is imparted to the membrane by
the copious vascular supply from so many large adjacent sources,
I have had within the last few days an opportunity of deter-
mining ; for, having placed a piece of cotton moistened with oil
within the remnant of the membrana tympani, which, except at
the upper portion, scarcely advanced within the tympanic groove
of the meatus, I was astonished to find that it pulsated in like
manner with the membrane, receiving, I presume, the impulse
from the arterial circle still remaining in connexion with the
groove to which that structure had been originally attached.

* In cases of long-cuntinued iuflammation of the iris, large red v^sels can be seen
ramifying on its surface ; but, in acute cases, I have lately been able to determine, with
the aid of a strong magnifying glass, that the rusty or brownisli-red unelevated spots seen
on the corneal aspect of that membrane pruve to be nothing more than congeries of ves-
sels carrying red blood.

t See a case of Otorrhoea with perforation, and description of a new diagnostic symptom,
in the Medical Times and Gazette for 27th March, 1852, No. 91.

MALFORMATIONS OF THE HEMDRANA TTMPANI. 219

The membrana tympani is in health the drycst membrane in the
body, — is it hygroraetric, or capable of imbibing moisture from
the surrounding atmosphere, and thus becoming more or less
tease, according to the medium in which it is placed? I believe
it isy although it is difficult to offer proof thereof. Certainly pa-
tients labouring under partial deafness affirm, that on dull moist
days, or in damp weather, they cannot hear so well as when the
atmosphere is dry and clear. How much of this depends upon
the atmosphere considered as a medium for conducting sound, or
upon the condition of the membrana tympani itself, we have yet
to learn. There are other subjects connected with the state of
tension, amount of curvature, and degree of flattening or collapse
which the membrane occasionally presents, that might be consi-
dered here, but that they properly belong to the pathology of this
part

I have dwelt thus long upon the anatomical characters of the
membrana tympani because it is that part of the ear least known to
students or practitioners ; and because in it will, according to my ob-
fK*rvationB, be found characteristics of disease and pathological
changes from the normal structure, sufficient to account for at least
two-thirds of the cases of impaired hearing, independent of me-
chanical impediments from wax, and the inflammations presenting
otorrhcea which occur in practice. It is true that the pathologi-
cal condition or amount of disease seen upon the external surface
of the membrana tympani is frequently insufficient to account
for the degree of deafness; still such changes, which are visible
to tHe eye, are indicative of certain conditions of the middle ear
which are beyond our ken, — in the same manner as the state of
the cornea and iris, which we do see, are characteristic of certain
changes in the parts beyond (the choroid and retina) which have
proved destructive to vision, which we do not see ; and the
amount of mechanical defect is seldom commensurate with the
extent of mischief in the scnsient parts beyond.

MALFORMATIONS OF THE AIEMBRANA TYMPANI.

Where the external auditory canal or the tympanum is deficient,
or closed by bone, the membrana tympani must, as a matter of

220 IMJUKIES OF THE MEMBRANA TTMPANI.

course, be wanting. Cases have been recorded in which a false
membrane covered the membrana tympani. The only instance I
have seen of irregularity in the membrana tympani consisted in
malposition of the attachment of the malleus. Upon examining
the ears of the pupils in the Institution for the Deaf and Dumb at
Claremont, I observed two instances in which the manubrium, in-
stead of occupying its usual position, passed forwards towards the
lower and anterior attachment of the membrane. In a third, the
membrana tympani was one uniform, concave membrane, without
the slightest vestige of any of the ossicles within it, and I have
seen a similar case in private. It is believed that the hole which
Rivinus considered as a normal formation was, in the instances
which he examined, an accidental malformation.

WOUNDS AND INJURIES OF THE MEMBRANA TTMPANI.

Injuries of the membrana tympani^ independent of those arising
from inflammation or its consequences, may be caused by pene-
trating instruments or foreign bodies passing through from the
external meatus; rupture in whole or in part by external violence,
such as fracture of the temporal bone, blows on the side of the
head, or falls, &c. ; and loud sounds, concussions, or the sudden
impression of a stream of air from within the tympanum, when
the membrane is in a particular state of tension, and, perhaps, I
should add, of dryness. I have already given instances of foreign
bodies passing through the membrana tympani ; and many cases
have been recorded of the membrane having been perforated by
the accidental introduction of penetrating instruments, or even pins
and ear-pickers. Sir Astley Cooper relates a case of laceration of
the membrana tympani caused by a box on the side of the head,
extending from above downwards across the entire membrane.
When bleeding from the ears occurs in hooping cough, sudden
violent congestion, or strangulation, I suppose the haemorrhage
comes from the middle ear through the burst membrana tympani.

Case No. 58 in the Registry is that of a man aged 40, who,
in a fit of intoxication, fell against the street railing, and was car-
ried home insensible. He had considerable haemorrhage from the
left ear both at the time and for several hours after. Having lost

IHJUBIB8 OF TUB MEMBRANA TYMPANI. 221

the hearing completely on that side, he applied at the hospital one
month suhaequent to the accident. The membrana tympani was
rather opaque, and a well-marked cicatrix running from above
downwards, anterior to the malleus, could be observed ; it was of
a dense white colour, but became red upon the tympanum being
inflated. A second case, that of a female aged 30, No. 122 in
Registry, presented somewhat the same appearance from a blow
on the right ear, followed by haemorrhage, but the accident had
occurred three years before I saw her. The subject of haimorrhage
from the ear not having been yet sufficiently investigated in a pa-
thological or a medico-legal point of view, a wide field for inquiry
into this subject still exists. Bleeding from the ear has been re-
marked in persons ascending to great elevations, as well as in
descending in diving-bells; and professional divers, likewise, ex-
perience the same affection. Diving to any depth is a frequent
caase of rupture of the membrana tympani; I have seen two in-
stances in which it occurred. A gentleman, when in a warm bath,
having allowed some of the water to get into his external meatus,
thrust in his finger forcibly, with the intention of dislodging it,
when he felt something burst in his ear, and he immediately per-
ceived the water in his throat. I saw him a short time after, when
the parts were considerably inflamed. There was a small rupture
in the inferior portion of the membrane. The gentleman was for
a long time after the accident in the habit of applying a drop of
fluid with the point of his finger into the meatus, and letting it fall
into the aperture in the membrana tympani, — a practice which
many persons, with perforations in the lower portion of the mem-
brana, are familiar with. A lady, whose ears I had examined a
few days previously, and in whom the membrana tympani was re-
markably thin and dry, sent for me to say that, while blowing her
nose violently, something had suddenly burst in her ear. Upon
inspection, an hour after the accident, I found an aperture in the
anterior vibrating portion of the membrane of a triangular shape,
with lacerated, everted edges ; a slight streak of blood surrounded
the rent; there could be no doubt as to tlie cause of the rupture.

Any loud, sharp report, such as that from a piece of artillery,
may cause temporary, or even permanent, deafness, rupture of

222 INJURIES OF THE MEMBRANA TTHPANI.

tlic membrana tympani, and haemorrhage from the meatus. Ar-
tillery recruits frequently suffer from bleeding from the ears, but
the exact cause has not been yet fully ascertained.

Surgeon Thornton of the Royal Artillery, to whom I addressed
a letter on the subject of haemorrhage, tinnitus, and deafness in
gimners, writes to me as follows: — ** Many of the men state that
they have seen haemorrhage occur, but it is not so frequent as is
supposed ; dulness of hearing is, however, very common, espe-
cially among old gunners. The effect of position, with reference
to the gun, is peculiar, — those men who stand nearest the muz-
zle feel the report most, but all who are to leeward suffer more
than those to windward. Braids ordnance ring louder and make a
sharper report than iron guns, — the usual effect of which, as I have
myself experienced, is that of receiving a smart blow upon the
tympanum ; this, however, soon passes off, and leaves a singing
or tingling sensation in the ear for two or three days. Another
peculiar sensation is that of having water in the ear, as if after
bathing. After some practice the ear becomes accustomed to the
shock, and men learn by experience where to stand so as to feel
the concussion least."

In one of the artillery now quartered in Dublin, who suffered
from haemorrhage from the ears the first time he was at field prac-
tice, fifteen years ago, and whose ears I examined this day, I
found a small, white, well-defined line or cicatrix proceeding from
above downwards behind the manubrium of the malleus, than
which it is a little shorter. Both ears presented precisely the same
condition, and the haemorrhage, he says, was equal upon each side.
The rest of the membrane is normal ; he is not deaf

A medical practitioner at Portsmouth has kindly afforded me
the following note of his own case : — " I was standing about half
a dozen yards from a large cannon when it was fired for a salute.
At the instant the gun was fired I felt a very severe shock, but
unattended with pain, in my right ear, whicii was that nearest the
cannon. I immediately perceived that I had lost all power over
the right side of my face. In fact, I had suddenly become affected
with * Bell's paralysis.' At the end of ten days, finding I did not
recover, I applied a blister to the back of my neck, lived sparingly,

INFLAMMATIONS OF THE MEMBRANA TTMPANI. 223

and took a sufficient quantity of calomel to afTect my gums slightly.
Not deriving the benefit I anticipated, I went to London and
consulted Sir B. Brodie, who recommended me to discontinue all
treatment and to live generously ; when I soon got quite well."

I was consulted by Captain H. some years ago, on account of
total deafness of the right car, attended with an incessant buzzing
noiae. He stated that he lost his hearing instantaneously while
grouse-shooting. His gun had been overcharged, and '* kicked**
80 violently as to cause him to stagger; he felt a sharp pain in
his ear, and became conscious of his loss of hearing immediately.
The membrana tympani was very much collapsed.

I believe that the best treatment which can be adopted for re-
cent injuries of the membrana tympani is to let them alone, unless
inflammation should arise, when it must be met by local depletion,
&c. It is remarkable that, while we experience the greatest diffi-
culty in keeping open a perforation made with a surgical instru-
ment, accidental openings seldom close.

INFLAMMATIONS OF THE MEMBRANA TYMPANI.

Myringitis, or inflammation of the membrana tympani, has not
been recognised or described by authors until within the last few
years: and its varieties, with their peculiar symptoms, are by no
means accurately understood. Itard, one of'tlie earliest and most
esteemed writers upon aural surgery, has not mentioned it, though
the symptoms of at least one form of the disease are enumerated
by him under the head of internal otitis. The old divisions of
inflammations of the ear into otitis externa and interna do not
in any way assist either our diagnosis or improve our treatment,
and the same maybe said of the divisions into acute and chronic.
The otorrhoea which follows in such cases, and which formed,
with many writers, grounds for nosological arrangement, being but
a symptom, like that of leucorrhoea in the female, is an insufficient
ground of diagnosis.

Lincke, as already shown at page 144, classes the aural inflam-
mations according to their causes, as the erysipelatous, scrofulous,
syphilitic, &c. ; but the exact locality or seat of the original in-
flammation, or the peculiar appearance of such, are not specified.

224 INFLAMMATIONS OF THE MBMBRANA TTMPANI.

These are merely enumerations of diseased actions, generally cha-
racterized by muco-purulent discharge, attendant on, or following
these different affections. He was, however, one of the first ac-
curate describers of the *^ JEntzundung des Trommel/ells^^' the true
Myringitis.*

Kramer, in his first work, gave a section on acute inflamma-
tion of the membrana tympani, but upon a careful perusal of it
we find about four pages devoted to the description of that clis-
ease, while the remainder is occupied with the consideration of
polypus, and a detail of the various methods recommended for
performing perforation.

Mr. Pilcher disposes of inflammation of the membrana tym-
pani in a few pages, but enumerates most of the symptoms of
the affection (except the minute appearances of the membrane),
under the head of otitis interna. Mr. T. W. Jones has given a
short description of one form of the disease. I cannot, however,
agree with him, that in '* otitis interna morbid changes in the mem-
brana tympani occur only when it is threatened with bursting by
the matter accumulated in the cavity of the tympanum, and has
also become involved in the inflammatory action."^ On the con-
trary, my experience leads me to believe that inflammation of the
middle ear always, and at the very commencement, is shown by
the appearance of the membrana tympani ; and this observation
must remain undisputed until a sufficient number of accurate
examinations shall have been made, in the commencement of
cases of otitis interna, to negative it. It is quite plain from Dr.
Williams's account of the ** inflammation and ulceration of this
membrane,"* that he never examined the membrane in this con-
dition ; indeed, I doubt if he ever saw the disease under consi-
deration.

Dr. Martell Frank has given a concise but faithful descrip-
tion of both the acute and chronic form of the disease. M. Hu-
bert-Valleroux does not even enumerate the inflammation of
the membrana tympani in his catalogue of aural diseases; and
Schmalz has done little more than glance at the disease. He has

• From myringa — myrinx, — the membrane of the Uruin.

IHFLAMMATI0S8 OF THB MEMBRANA TYMPANI. 225

evidently mixed up the description of its symptoms with those of
other inflammatory affections of the ear.

In the following cases and description, the inflammations of
the membrana tympani have, in many instances, been connected
with those of the middle ear, because I do not believe it possible
for one to exist independent of the other for any length of time :
no more than an ophthalmia can be circumscribed, or than we can
by the term iritis define a simple uncomplicated inflammation of
the membranous diaphragm of the ocular chamber.

By the term myringitis the reader is to understand inflamma-
tion of the membrana tympani ; and by tympanitis^ inflammation
of the cavity of the tympanum.

Abscess in the membrana tympani must be a very rare disease.
In the year 1843 I had opportunities of seeing two cases of a cir-
cumscribed deposit of pus between the layers of the membrane ;
each was about the size of No. 6 shot ; and in one instance, when
I punctured the abscess with a cataract needle, a small drop of
pus oozed out.

I have, in the nosological chart at page 148, enumerated the
various inflammations to which the membrana tympani is liable,
but for all practical purposes the following forms, with which I am
myself familiar, will suffice : —

1. Acute inflammation of the membrana tympani, commencing
in the fibrous layer, accompanied by inflammation of the cavity
of the tympanum; frequently of a rheumatic character.*

2. Sub-acute inflammation, unaccompanied by pain.

3. Syphilitic inflammation.

4. Strumous inflammation, generally in the mucous layer, with
mucous engorgement of the tympanum.

* This enuroeratioD, bot somowhat differently arranged, is that which I adopted in
my Essay npon *^ Inflammatory Affections of the Membrana Tympani and Middle Ear,"
pnblished in 1848, and I have not since seen reason to alter it or render it more minute.
In Mr. Harvey*8 book upon " Rheumatism, Gout, and Neuralgia," &&, of the Ear, he
states, in the opening paragraph, that, *' Rheumatism affecting the structures of the ear
has not hitherto, as far as my researches have enabled me to ascertain the fact, been noticed
in amy medical work." Now, both Lincke and Frank have given descrii)tions of gouty and
rheumatic otitis ; and Mr. Har\'oy has quoted at length a well-marked instance of ** se-
vere rheumatic inflammation of the membrane and cavity of the tympanum," from wy
Essay already alluded to.

R

226 ACUTB HTRIKQITIS.

5. Chronic inflammation, with or without inflammation of the
cavity of the tympanum.

6. Febrile inflammations, accompanying the exanthcmatic and
other fevers, extending from the tympanum, and generally pro-
ducing otorrhosa.

ACUTE HTRINQITI8.

In actde inflammation of the membrana tympanic the vascula-
rity is generally seated in the true fibrous structure, and is usually
the result of cold, and often attributed to rheumatic diathesis,
sudden exposure to a low temperature, blasts of harsh cold wind,
diving in the sea, foreign bodies, and irritating substances intro-
duced into the external car, &c. The auditory canal, and some-
times even the auricle, is engaged ; and although we are not able
to observe the precise pathological condition of the cavity of the
middle ear, or its investing membrane, there can be little doubt
but these parts, sooner or later, participate in the general inflam-
matory action. As, however, we denominate that form of internal
ophthalmia which chiefly or primarily attacks the iris, an iritis,
although, in the severer kinds of that affection, several if not all,
the other textures of the eye eventually become engaged, so in in-
flammations of the membrana tympani, to which the term my-
ringitis is applicable, we must expect that sooner or later the
adjoining structures, — the mucous membrane lining the tympa-
num, with its numerous nerves, the nerves which cross this ca-
vity, the periosteum, the mastoid cells, the investitures of the Eus-
tachian tube, the membrane of the fenestra cochlese, the muscles,
ligaments, and other connexions of the ossicula, the labyrinth, the
internal ear, and the auditory nerve itself, — will sooner or later
participate in the unhealthy action going forward; and which
must, either directly by the inflammatory lesion, or its subsequent
effects, serve to impair hearing, and cause organic changes in this
delicate organ. But in addition to the alterations analogous to
those which occur in ophthalmic inflammations, we may have,
from the peculiar anatomical structure of the ear, an extension of
disease to parts which not only destroy the sense of hearing, but
prove dangerous to life, as when the bone, the membranes of the
brain, or the enccphalon itself, become engaged.

ACUTB MYRINGITIS. 227

The dermal structure partakes of the abnormal action, and, to-
gether with that of the auditory canal, pours out a muco-purulent
■ecretion, or even pus itself, — is occasionally raised into vesicles,
becomes the seat of pustules, ulcerates, throws out granulations,
and becomes thickened, <S5C., during the progress of disease. The
true fibrous membrane passes through all the pathological changes
to which such structures are liable from inflammatory action or its
refolts; and although the precise anatomical condition of the two
may not be analogous,. yet the diseases of the cornea and of the
membrana tympani bear a remarkable analogy, particularly in the
subsequent appearances of vascularity, thickening, opacity, and
morbid deposits, &c., which they present, together with adhesions
by bands of membrane to the parts within the chambers, to which
they form the external boundaries.

The following are generally the order of symptoms. A seizure
of sudden and intense pain in the ear itself, most generally first
appearing at night, and attended with nocturnal exacerbations
during the progress of the disease. This pain is of a most excru-
ciating kind, producing at times delirium, and is usually likened
to that of a sharp instrument penetrating through the ear to the
bndn: it is, especially when the cavity of the tympanum is en-
gaged, increased by coughing, sneezing, blowing the nose, chew-
ing, or swallowing, or by pressing upon the tragus, particularly
when the jaw is open. The beating of the carotid is distinctly
felt in the ear, and each throb of the artery, especially if the
circulation be excited, increases the suffering; and there is fre-
quently a feeling of fulness and bursting within the organ. With
this there is also pain and soreness over the side of the head, in
the teeth, in the eye and temple, and in the superior lateral tri-
angle of the neck ; with occasionally stiffness and soreness of the
upper portion of the mastoid muscle, and often flying rheumatic
pains throughout the body, particularly in middle-aged persons,
and those who have previously suffered from rheumatic attacks.
If neglected, or unrelieved by treatment, the pain extends to the
throat and mastoid region, and is increased on pressing the mouth
of the Eustachian tube with the finger. The severity of the pain
experienced, and the extent of soreness to the touch, is to a cer-

r2

228 ACUTB MYRINGITIS.

tun degree a test of the amount of the inflammation ; and the pe-
culiarity of the pain is also a means of judging of the seat of the in-
flammation ; for if it is experienced in swallowing, mastication,
or sneezing, <Sx;., we may presume that the inflammation has ex-
tended over the middle ear.

I have known a man to be treated for inflammation of the brain
who merely laboured under inflammation of the ear ; and on the
other hand a very curious impression exists among, and is too fre-
quently acted on by, the profession, that. ear-ache is a neuralgic
afiection. To this very general mistake must we attribute the
practice, so frequently and empirically resorted to, of pouring into
the ear the various nostrums — sedatives, and stimulants, calculated
to allay pain in external parts. So rare is true neuralgia of the
ear, that Dr. Kramer says, he ** never observed ear-ache without
evidence of inflammation either of the meatus or of the membrana
tympani." Although I am not prepared to go the length of saying
that such an afiection does not occasionally exist, I must say that
I cannot tax my memory with more than one or two instances of
so-called ** nervous otalgia,*^ for which I have been consulted, that
upon a careful examination I could not discover some direct visi'
bU cause for it: and I must, therefore, with Dr. Kramer, "deny
to those persons the right of pronouncing a decisive opinion on
the existence of a nervous otalgia, who do not understand inves-
tigating the membrana tympani in bright sunshine, and with the
aid of the speculum, and who are not in the habit of doing it."*

Usually coincident with the seizure of pain, the patient com-
plains of tinnitus autium, and the noises are described as a dull
throbbing, or pulsation, — a loud pumping like that of a steam-
engine, — with the occasional supervention of a sound varying in
loudness and intensity from the ticking of a watch to the striking
of a loud clock ; but the most usual simile given by patients in
describing those ear-noises is that tidal sound perceived on hold-
ing a conch-shell to the ear. In the severer forms of aural inflam-
mation, patients very frequently liken this unpleasant symptom to
the falling of water, the dashing of a cataract, or that peculiar
rushing sound produced by the sudden escape of water through
a large pipe or sluice-gate. In the more mitigated forms, and the

ACUTB MTRINGITIS. 229

more advanced and chronic stages, we generally find the sounds
of a hissing or blowing character, and usually likened to the sing-
ing of a kettle, the noise of a distant storm, the fluttering of the
leaves of trees, the chirping of birds, the distant ringing of bells, a
didl cooing in the ear, musical sounds of various kinds, the buzz-
ing of bees, blowing of bellows, whistling, and other noises of a
similar character, to which I have already referred at page 82.
Any increase of the circulation, or nervous excitement of any kind,
particularly in irritable patients, invariably makes these ear-noises
worse.

Deafness — consisting either of impaired hearing or total loss
of that sense on the affected side — comes on contemporaneously
with the pain, or succeeds it in a few hours after ; if, however, but
one side has been attacked, the patient is not at first conscious of
his loss of hearing. In some rare cases there is for a short time
daring the progress of tympanal inflammation an exaltation of the
sense of hearing, in which (like photophobia in ophthalmia) all
sounds become intolerable.

In severe inflammations of the ear, pain in the teeth of the
affected side is no uncommon accompaniment; and pain from
toothache, with or without decay in the last molar, is often re-
ferred to the ear. We should, therefore, carefully distinguish be-
tween these two causes. I think dentists too frequently, and with-
out examining the state of the meatus, tell patients labouring
under ear-ache to *^ wait until the teeth are set right.** In cases
of chronic ear-ache, the state of the last molar tooth should always
be examined.

To these local subjective symptoms may be added the following
constitutional ones : coryza, sneezing, coughing, and other symp-
toms of catarrh, increased heat of skin, headach with a feeling of
weight in the head, and sometimes well-marked hemicrania ; there
is always great distress and anxiety of countenance ; sleeplessness,
restlessness ; nocturnal exacerbations, the acute pain coming on at
a particular hour ; quickness of pulse, occasionally rigors, in some
instances delirium, and even, in very bad cases, all the symptoms
of cerebral disease, of which the case at page 238 is an example.
The digestive organs are seldom much engaged in the progress

230 ACUTB MTBINQITIS.

of the disease ; the urine becomes high-coloured, and, towards the
termination of the acute symptoms, deposits a copious pinkish sedi-
ment. The circulation, except in very severe cases, is seldom
much affected.

The physical signs consist, in the severe cases, of heat, pain,
and slight erysipelatous redness of the auricle : in very aggravated
cases, — heat, fulness, and oBdema, as well as pain over the mastoid
region, and great soreness of the scalp on the affected side. In
ordinary cases there is slight tumefaction of the lining of the ex-
ternal meatus; complete cessation of the cerumenous secretion; a
bright pinkish colour ; a swelling and polish of the lining of the
auditory canal, which is streaked with long tortuous vessels, ac-
companied by heat and itching of that part, and all the symp*
toms of inflammation described at page 194. The membrana
tympani first loses its polish, then its semi-transparency, — becomes
in the early stages, and in very mild cases, of a dull yellow, but
this is variable and seldom seen; the most usual colour varies
through all the shades of red, from a slight pinkish hue to that of
a dark damask rose tint, and is caused by the different degrees of
vascularity produced by the greater or less intensity of the inflam*
mation, the structures engaged, and the medium through which
we see the vessels. In addition to the vascular arrangement
figured and described at page 216, new vessels seem during
inflammatory action, like as in the coats of the eye, to start into
existence, and to branch and inosculate till the whole seems one
mass of bright livid red. Generally speaking, the upper portion
around the attachment of the head of the malleus is the first to
become vascular, the last to regain the natural hue, and the part
in which the colour becomes deepest. The vessels alongside the
handle of that bone are always well marked, though the line of its
attachment remains for some time whitish, owing to the intimate
connexion of the membrane to it at this part. Around the cir-
cumferential ligamentous ring, particularly at its lower and an-
terior part, an areola of short vessels form a crescent of almost
a line in breadth ; they all run towards the centre, and, when
well marked, look like the zone seen in iritis, or that observed
in the edge of the cornea in the commencement of corneitis, to

ACUTB MTRINQITIS. 231

which difleaae the appearances seen in myringitis bear a great
resemblance. It is only in the early stage, or when the redness
is disappearing, that this peculiar peripheral vascularity is well
marked. With this general redness may, in some cases, be
seen well-defined patches of ecchymosis, generally on the anterior
vibrating portion ; but as the vascularity increases, even the exact
position of the manubrium cannot be recognised, — all is one red
mass. The membrane also becomes swollen, and its surface ap-
parently villous ; rarely vesicles, and still more rarely pustules, form
on its surface. Ulcers occasionally form upon it; these usually
occupy the anterior part of the lower vibrating portion, but I
have occasionally seen them situated posteriorly. It is possible
that they may have commenced as vesicles or pustules, but we
require more extended and minute observations to determine this
point.

Exudation of lymph and muco-purulent secretion, with de-
tachment of the cuticle, both from the surface of the membrane
and the parietes of the canal, follow. Lymph is very frequently ef-
fiised in the substance or between the laminse of its proper fibrous
tonic, and there can be little doubt that, in the severe forms of the
disease, this morbid product is poured out in large quantity upon
die surface of the tympanum, the membrane of which must par-
take largely of the inflammatory action so visible in the external
septum. That these lymphy exudations — both by thickening
the tympanal membrane itself, and by acting in a similar manner
upon the lining of the cavity of the tympanum and the parts
contained within it, by bands of adhesion within its walls, thus
drawing inward and arresting the vibrations of the membrana
tympani, curtailing the motion of the ossicula, injuriously affect-
ing the membrane of the fenestra, and particularly by impairing
the functions of those tympanic branches of the glosso-pharyngeal
nerve which ramify on the mucous membrane — are the principal
causes of deafness, I have little doubt. Perforation of the tym-
panal membrane, either by rupture, abscess, slough, or ulceration ;
but which it is not always easy to determine, also occurs occasion-
ally. When rupture takes place, and that accumulations of bloody
mucus, or purulent matter, pent up within the tympanum, are

232 ACUTB MTBINQITIS.

evacuated, relief is generally experienced. In this condition — with
the cavity of the tympanum open, polypoid growths occurring in
the meatus, and granulating over the surface of the tympanum,
and a copious and very often fetid discharge pouring both from
the auditory passage and the drum — the case becomes one of otor-
rhoea, the peculiar symptoms and management of which are de-
tailed in the chapter on that subject.

In cases where neither rupture nor ulceration has taken place,
as the disease advances, the vascularity of the membrana tympani
decreases, first in the centre of its vibrating portion, then around
its circumference, and finally along the mallear attachment. The
membrane assumes a muddy, yellowish, opaque colour; after this
clears off we find it opaque throughout, or in spots ; sometimes
these opacities can be plainly discovered upon the interior of the
membrane, like the speckled opacities seen upon the membrane
of the aqueous humour. In other cases, the result of the inflam-
mation is seen in the uniform greyish-white opacity, similar to
leucoma of the cornea ; and in time, as the superficial polish is re-
stored, the membrane presents a pearly aspect very different from
the semi-transparent character of the healthy condition.

A not uncoinmon effect of inflammation of the tympanum and
its membranes, particularly when allowed to run its course un-
checked, is collapse on a drawing inward of the membrana tym-
pani, as explained at page 138. In such cases the handle of the
hammer forms the most projecting point seen at the bottom of the
auditory canal ; and the anterior and posterior divisions of the
membrane can be distinctly observed forming deeply curved folds
upon either side of it.

The inflammatory process must, in severe cases, also extend
into the mastoid cells ; the periosteum lining the bony portion of
the auditory canal will in time become engaged, as well as the
pericranium over the mastoid process, and post-aural region of the
skull, and present the symptoms already described. If allowed
to proceed unchecked, by the efforts of nature or by art, the
death of the bone beneath will follow ; while, in cases still more
severe, the entire petrous portion of the temporal bone will be-
come inflamed, — the dura mater will separate from it, — purulent

AGUTB MTBINGITIS. 233

deposit takes place in the cavity thus produced, — the brain, as
well as its investments opposite those portions, will partake of the
inflammation, — and death follow, either from abscess, or diffuse
inflammation of the cerebrum or cerebellum.

In some rare cases, paralysis of the muscles of the face, on the
afiected side, presenting all the peculiar phenomena of that disease,
is produced ; instances of which will be related hereafter.

During the progress of the inflammatory action in the tympa-
num and its external membrane, the throat, in some cases, becomes
engaged, its mucous membrane presenting a copperish-red appear-
ance, and becoming swollen and infiltrated. The tonsils are
also swollen ; there is some difficulty of deglutition ; and if an
examination of the pharyngeal extremity of the Eustachian tube
be made with the finger, according to the method described at
page 80, considerable pain is experienced in the track of the tube,
as well as in the middle ear. There can be little doubt of the
inflammatory condition of the middle ear, extending over the
Eustachian tube, and causing such thickening and obstruction of
its lining membrane, with, perhaps, an accumulation of mucus, as
greatly impedes the transit of air into the drum, and causes that
peculiar feeling of stuffing, and occasional sudden bursting in the
middle ear, of which we are all conscious when labouring under
influenza or catarrh.

The nose sometimes partakes in the unhealthy condition of
the neighbouring mucous membrane, and a feeling of stuffing
in that part, together with much faucial respiration, is not an un-
common attendant upon acute inflammation of the middle ear and
membrana tympani.

This form of inflammation chiefly attacks the young and mid-
dle-aged ; one ear is much more frequently affected than both ; the
light-haired and fair-complcxioned are more liable to it than the
dark. So much more frequent are its attacks in spring than at
any other period of the year, that it sometimes seems to be epide-
mic at that time. The duration of the disease varies from six to
fourteen days, but may last a month, and its efifects several months.

In the foregoing description it was impossible to avoid details
and symptoms common to inflammation of the cavitas tympani —

234 ACUTE MYRINGITIS.

true otitis — and its membranous partition, because the diseased
action sooner or later extends from the one to the other.

With respect to treatment, the temperature in cases of acute
myringitis should be strictly attended to : the patient should, if
possible, be confined to a warm, well-ventilated apartment, or, if
obliged to go abroad, the cold air should be carefully excluded
from the ear ; but in the severe form of the disease it is absolutely
necessary to confine the patient to bed.

I have never had occasion to employ general bleeding ; but
local depletion, either by means of cupping or leeches, is invari-
ably necessary ; and leeches are not only the most effectual and
easiest mode of abstracting blood, but they can be applied nearest
the seat of disease, and repeated as frequently as necessary. To
be effective they must be applied according to the directions which
I have given at page 85, to which I would here particularly direct
the attention of the reader. The auditory canal having been filled
with cotton wool, to prevent them going in too far,* and the
blood from flowing into it, five or six leeches should be attached
round the external meatus, the direct vascular communication of
which with the membrana tympani I have already pointed out
at page 217. I fallowed to scatter over the concha, they will
not afford the same amount of relief: but several may be applied
in front of the tragus, and others, if necessary, close into the an-
gle between the auricle and the mastoid process. The bleeding
should be encouraged by warm applications, stupes, and poultices,
and, if necessary, kept up by relays of leeches for eight or twelve
hours together. The relief afforded by leeches in this disease is
often instantaneous, and is always most marked.

The employment of moist heat, as directed at page 89, will

* I knew one instance in which, from the omission of the cotton, a leech attached itself
somewhere within the meatus, and caused
the most excruciating agony. Although I
generally mark the places to which the
leeches should be attached with spots of
ink, I have frequently the mortification of
finding that they have been allowed to at-
tach themselves to places tax remote from the edge of the meatus. The apothecary
should bring with him a laigc quantity of leeches, and employ the glass here figured
of the natural size.

ACUTE MTRIKOITIS. 235

alwajrs afford relief. In addition I may mention, that applying
the tube attached to a Mudge's inhaler to the external auditory
paasagOy and allowing the warm vapour to have access to the in-
flamed parts, will give the patient great comfort.

When there is much external neuralgic pain, or rheumatic
soreness and tenderness to the touch about the external ear, and
over the side of the head and face, relief will be experienced from
the various sedative applications, of which I may mention three,
— ^tincture of aconite, chloroform, and the belladonna with com-
pound camphor liniment. There are two popular remedies for
*' a pun in the ear"* still in very general use, — the application of
a roasted fig, and the insertion into the meatus of a hot roast onion
or a clove of garlic. The former is innocuous, the latter is by no
means harmless. The empirical practice of pouring laudanum and
oil into the ear the moment pain is complained of, employed by
the profession, is, I trust, on the wane.

The bowels should in this, as in all other febrile diseases, be
opened, but the condition of the digestive organs does not appear to
influence the inflammatory affections of the ear as much as they do
those of the eye. The state of the skin, however, which is gene-
rally hot and dry, requires our more especial attention ; and sudo-
rifics are, in the early stage of the disease, decidedly indicated.
Having leeched, fomented, and purged, Jameses powder, combined
with small doses of blue pill and henbane, will be found very effl-
cacious. Abstinence from animal food, and the use of the foot-
bath, together with all such means as arc calculated to allay
inflammation and febrile excitement, should be had recourse to.

Counter-irritation, by means of small blisters applied upon the
bald space behind the auricle, and below the lobe, are advanta-
geous in the more advanced stage of the disease, and after local
depletion has been fully employed. Generally speaking, blisters
are too much relied upon, or applied too early in the disease ; but
as it advances they will be found highly useful.

Having resorted to all those means, we should, if the symp-
toms— ^not only of pain and deafness, but of the redness and vas-
cularity of the tympanal membrane^ — remain unrelieved, at onco
have recourse to the use of mercury. Indeed I am now so fully

236 ACUTE MTBIMQITIS.

convinced, not only of the utility, but of the urgent necessity of em-
ploying mercury in these aural inflammations, that I do not hesi-
tate to recommend its use in the early stages of all such affections.
A pneumonia, a pericarditis, a peritonitis, an inflammation of a
large joint or a serous cavity, or an iritis, may, it is true, get well
by simple depletion, &c. ; but will any experienced practitioner of
the present day risk such a case without having recourse to mer-
cury ? For the reasons applicable in these instances, — from the
peculiar effect which mercury exercises, not only in most inflam-
mations, but especially over those of flbrous membranes ; and in
order to arrest the exudation of lymph, and to cause the absorp-
tion of those effusions which, by thickening the membrane, and
causing those pathological effects to which I have already so fre-
quently alluded, and which prove so constantly the cause of sub-
sequent deafness ; as well as the urgent necessity for arresting the
progress of inflammation in a part that may prove destructive to
life, — it is, that I so strongly advocate the employment of this re-
medy. I find that, in most instances, where it is employed early,
it produces, as soon as it affects the system, as well-marked an im-
provement in all the symptoms as it does in any of the other in-
flammations which I have enumerated. It should, therefore, be
given in small, frequently-repeated doses ; and the formula I find
most efficacious is calomel and blue pill, guarded with opium, and,
if the stomach will bear it, a very small quantity of James's pow-
der. Not only should the gums be touched, but the patient should
be kept under its gentle influence for some days, in order to insure
an ultimate beneficial result.

In the subsequent management of the disease, the iodide and
bromide of potassium, or very minute doses of the bichloride of
mercury in some of the preparations of bark, will certainly hasten
the cure, as well as promote absorption of the deposits and adhe-
sions already alluded to. The tinnitus which remains is more
likely to be removed in time than that attending chronic deafness.

The state of the meatus and membrana tympani should be ex-
amined with a speculum daily, or oftener if necessary ; and then,
should we discover an ulcer, it may be touched with a solution of
nitrate of silver applied with a fine camel's-hair pencil. If otor-

ACUTB MTBINGITI8. 237

riiGM has occurred either in the form of muco-serous exudation,
from the external surface of the tympanal membrane and the au-
ditory canal, or owing to pus or mucus escaping from the middle
ear through an aperture in the membrana tympani, or from abscess
in the walls of the external auditory canal, we should remove the
discharge by very gently syringing the part with simple warm
water, or the most bland, unirritating fluid ; but during the high
inflammatory process no astringent injections whatever should be
employed.

If polypoid growths of any magnitude sprout suddenly from
the auditory canal, they should be removed with the snare, or
touched with the solid nitrate of silver; and this latter, if properly
done, does not give rise to any fresh attack of inflammation.

Should the mastoid process, or the parts covering it, become
engaged, and that the methods already recommended fail to give
relief, or that even an indistinct sense of fluctuation can be dis-
covered, we should not long hesitate to make a free incision in
the periosteum there, at least an inch in length. In performing
this operation, the head should be firmly secured, and supported
against some unyielding substance, as the back of a high chair, or
the breast of an assistant. A stout scalpel is the best instrument
to employ : the blade should be grasped by the fore-finger and
thumb, so as to leave about an inch of it uncovered ; and inserted
steadily till the point reaches the bone, which it should be made
to traverse for the full length of the incision. By this means we
secure complete division of the periosteum. With regard to the
line of the incision, circumstances may require its being made in
other directions, but I find that it is most generally required pa-
rallel with, and about three-quarters of an inch from, the attach-
ment of the auricle, in order to avoid the posterior aural artery,
which, when divided, bleeds profusely. The knife should be
drawn from below upwards; and from the swollen state of the
parts, the depth which we are sometimes obliged to introduce the
instrument is often nearly an inch. The hasmorrhage, unless we
wish to extract blood, may be arrested by placing a dossil of lint
within the incision. The cut surfaces generally present the
brawn-like appearance seen in phlegmonoid erysipelas. Although

238 ACUTE MTRINOITIS.

pus may not have been reached by the incision, still immediate
relief is almost invariably experienced. The subsequent manage-
ment of this particular part of such a case must depend upon the
circumstance of exfoliation, &c.

The following cases exhibit many of the phenomena detailed
in the foregoing description. They are given at somewhat greater
length than would be necessary, were the diseases of the ear as
much attended to by the general physician or surgeon as they
ought, or if the treatment of those diseases formed a part of the
present system of medical education in these countries.

Acute myringitis and tympanitis in both ears, with severe
head symptoms ; recovery under the use of mercury.

Master J — , aged twelve years, with light hair and florid com-
plexion (whose elder brother had been under my care a short time
previously for chronic inflammation of the left, and acute inflamma-
tion of the right ear), had always enjoyed good health, and never
had any aural aflcction, till Sunday, the 1st of August, 1847, when
he was attacked with slight pain in the right ear. Upon the Fri-
day previous he had bathed in the open sea five times, and had
dived frequently each time. Upon the day following he bathed
three times, and also dived. He awoke on Sunday morning early,
with some pain in the right ear, but made no complaint, as he
says it was but slight; it was accompanied, however, by a feeling
of pressure, as if something was bursting out through the ear. He
bathed, however, again, twice upon that day. Towards evening
pain came on in the left ear, and increased greatly in the right.
He retired to rest early, and having been reminded of the provo-
cation for his pain, he made no further complaint. About twelve
o'clock that night, however, his mother was awoke by his cries
and moans, the result of the extreme agony which he was then
suflfering. A neighbouring practitioner was applied to, and some
camphorated oil and laudanum dropped into the ear. This treat-
ment, however, afforded him no relief, and he remained awake all
night, moaning much, and complaining of the violent pain in his
head and ears, which he likened to a sharp instrument penetrating
from without.

I saw him on Monday morning, the 2nd, about ten o'clock;

ACUTE MYRINGITIS. 239

the £tice was flushed, and the countenance anxious and expressive
of extreme pain. The pupils were rather more contracted than
naturaly and the eyes slightly sensitive to light; he had some heat
of skin, but the pulse was not above 76 ; the bowels were consti-
pated, and the urine natural. The auricle and external meatus
were normal; considerable pain was experienced upon pressing
the cartilage behind the articulation of the jaw, but pressure over
the mastoid region was borne with impunity. The auditory canal
was a light rose colour, quite dry, and devoid of cerumen ; the
membrana tympani was distinctly seen, with a deep pink colour
generally diflused over it, but increasing in intensity in a cresccntic
form round its lower insertion, and also in the line of the attach-
ment of the malleus. The appearances were nearly the same on
both sides. As this boy was brought to my house, I had a bettor
opportunity of accurately recording the state of the parts than one
is usually able to effect in the sick chamber. The appearance of
the throat was normal ; the Gnger pressed against the mouth of the
Eustachian tube caused but slight increase of the pain. Air passed
up with difiiculty into the tympanal cavity on making a forced
expiration. Hearing was then unimpaired.

He was ordered to be put to bed ; to take a purgative bolus,
and to have two leeches immediately applied to the posterior mar-
gin of the external meatus, as far in as possible, on both sides.
The leeches afforded some relief, but towards evening the pain
returned with great violence. He became quite delirious about
six o'clock ; did not know his friends ; and could with difficulty
be retained in bed. I saw him about eight o'clock ; he was then
in high fever, but more sensible ; there was great heat of skin ;
pulse 80, and fuller than in the morning; tongue clean; bowels
had been fully opened ; urine free and limpid ; no thirst ; knows
all his friends now, but does not pay much attention to what is
going forward about him ; is quite rational when spoken to; com-
plains of intolerance of light ; face has become more flushed and
anxious ; complains now of the great weight of his head, which he
rolls about from side to side ; has had no sleep. On examination I
found that the redness of the passage and membrane of the drum

240 ACUTE MYRINGITIS.

had greatly increased since morning, but there was no tumefaction
of either. Pressure or percussion of the mastoid process, and the
infra-aural region, was borne without wincing. Two more leeches
were ordered to be applied over the articulation of the jaw, in
front of the tragus upon each side, and small doses of calomel,
opium, and James*s powder to be administered every third hour.
The ear to be steamed over hot water, and a linseed poultice to
be applied subsequently. Scarcely any diminution of hearing.

3rd. Has passed a sleepless night, raving occasionally. All
his previous symptoms continue unabated, in addition to which,
he now, for the first time, complains of noise in his ears, which he
likens to that of the tide, and which is, he says, generally diffused
through the head as well as in the ears. The pain has somewhat
increased ; he says he feels as if a lance was running into his head ;
bowels free. Blisters ordered to be applied behind the ears upon
both sides. During the night of Tuesday he again became vio-
lent, and did not know his friends. The urine became remarkably
dark-coloured. He had no sleep. The mercury was steadily per-
severed in, and towards morning he complained of some soreness
of his mouth and gums.

4th. He passed another sleepless night ; raved occasionally ;
countenance less anxious; pulse not so full; pain in ears and head
very much less ; mercurial fetor ; mouth slightly sore ; complains
of pain in swallowing, which he refers to the middle ear. He has
become very deaf; says the noise has increased, and is now of two
kinds, — a continuous, uninterrupted bellows sound, and an occa-
sional ticking, like that of a loud watch, which commences and
stops suddenly ; membrane and passage unaltered. Interval be-
tween doses of mercury increased.

5th. He is much better in every respect; has had no delirium
since last report ; lies quiet on his side ; he is remarkably tranquil,
and has had some sleep ; the light is still offensive to him ; skin
cooler ; pulse 80 ; bowels free ; mouth very sore ; deafness still
continues ; noise in head not so violent ; urine high-coloured ; the
membrana tympani and auditory canal are much less red. Mer-
cury omitted ; the occipital region was ordered to be shaved, and

ACUTE MTBINQITI8. 241

two small blisters to be applied behind the insertion of the mas-
toid muscles. His chief complaint now is of the soreness of his
mouth from the effects of the mercury.

6th. At eleven o'clock this morning he was suddenly attacked
with acute pain in both ears, of a sharp lancinating character.
Leeches were again applied round the meatus on both sides, and
warm stupes and fomentations also had recourse to. These means
afforded him relief in a short time.

7th. Has slept well during the previous night; had no return
of the acute pain, but a dull aching still continues in both cars ;
he is very deaf to-day, but he is not so sensitive to light ; the bel-
lows noise still continues in his ears, and that which was formerly
described as the ticking of a watch, he now likens to the clapping
of two pieces of iron together. He only hears an ordinary ticking
watch when it is pressed against the auricle of the left side, not at
all on the right ; he does not hear it when applied to the forehead,
or held between the teeth, and but very faintly when applied upon
the mastoid process. He complains of a return of the weight in
his head to«day ; sleeps much ; bowels free ; urine of a dark brown
colour, and depositing a pinkish sediment ; mouth very sore. Upon
the visit at four o'clock in the evening the countenance was found
more tranquil than on any previous occasion ; the skin cool ; pulse
75 ; functions natural : pressure on the tragus is now borne with
impunity. Upon inspection, the membrana tympani was found
much less red, particularly on the left side ; it is also beginning to
dear above the malleus ; mouth still very sore ; ordered a gargle,
and to have light broth.

9th. Much better in every respect. A slight muco-purulent
discharge now appears from the meatus of the right ear. On re-
moving this with a little tepid water, and bringing the membrana
tympani within the 6eld of the speculum, the redness was found
to have greatly disappeared, except on two or three spots, about
the size of pin-heads ; all the intermediate portions of the mem-
brane had become white, and apparently thick and pulpy. Upon
the leftside a slight mucous discharge coats over the surface of the
membrane of the drum, and the inferior portion of the canal; hav-
ing removed this with a little cotton on a probe, the vascularity

s

242 ACUTB MTBIHGITIS.

which had previously appeared on those parts was found to have
greatly diminished ; but the membrane itself had become thick-
ened and opaque. He is quite free from pain ; the hearing dis-
tance has increased to about two inches on each side. On the right
side two small glands have now appeared beneath the lobe, and
another slightly enlarged over the mastoid process ; ordered three
grains of the hydriodate of potash three times a day, and nutri-
tious diet.

12th. Has very much improved in every respect since last report ;
18 now quite free from fever, but very weak and languid ; tongue
clean ; soreness of mouth quite removed ; pulse 60 ; has some appe-
lite ; sat up for a short time yesterday ; glands in the neck much les-
sened, that over the mastoid process still tender ; is quite free from
pain in the ears, but still complains of a slight, generally diffused
pain in his head ; there is no intolerance of light ; hearing dis-
tance has increased to eighteen inches on each side ; has had no
discharge from either ear ; the loud ticking noise has quite disap-
peared, but the buzzing or bellows sound is still slightly percep-
tible ; any surrounding noise is particularly distressing to him ; he
lays he feels as if it struck his ear. Upon examination of the
right ear, the passage is found to be quite dry, and of a light pink
colour ; the membrana tympani generally is somewhat redder than
on the occasion of my former visit ; and, besides this generally
diffused redness, there is a deep-coloured ring of vessels to be seen,
forming a crescentic band about a line in breadth, occupying the
lower portion of the membrane, the vessels of which can be dis-
tinctly seen running in nearly straight lines from the circumfe-
rence towards the centre. The projection of the malleus is marked
by a fasciculus of dark red vessels, running along the course of its
attachment. In the left ear the general redness of the passage and
the membrane is not so great, and there is no ring of vessels such
as exists upon the right side. He states that, on blowing his nose,
he felt as if something gave way in his right ear, and that imme-
diately his hearing increased, and on repeating the experiment a
few times, the same phenomena took place in the leil ear. Since
then his hearing has gradually improved to the present time ; he
was ordered to be blistered again behind the ears, to continue the

ACUTE MTBINGITI8. 243

of the potasli, to sit up for a few hours every day, and have
nutritious diet.

16th. Has continued to improve ; hearing has increased to three
jfeet upon the right, and four feet upon the left, side. The right
membrana tympani is found much less vascular but somewhat more
opaque than the left, which is still of a uniform pinkish colour,
but has, nevertheless, regained its polish and scraitransparency
much more than the other. The buzzing noise is still slightly
fislt. The blisters were repeated, and the potash, with tincture
of iodine, continued; slight open air exercise permitted.

18th. From the general improvement in his health, he was en-
abled to visit me at my house on this date. He states that the buz-
zing and all other noises have completely disappeared. The mem-
brani tympani on the right side is found to have lost much of its
yascularity, but is uniformly opaque, and is also dull upon its sur-
&ce ; with this ear the hearing distance is now four feet, whereas
with the left, which is still very vascular, but much more trans-
parent, the hearing distance is now full six feet. A generous diet,
and the potash and iodine ordered to be continued.

Sept. 25th. His general health is now quite restored ; his hear-
ing as good as ever ; the noise has entirely disappeared. During
the past month ablush of redness has several times appeared upon
the left membrana tympani ; still his hearing distance with that
ear is somewhat greater than on the right side, in which the mem-
brane is not vascular, but is slightly opaque.

The constitutional symptoms in this case were more than usu-
ally severe, and such as might lead the practitioner to suppose the
brain or its membranes were engaged. We also learn from this
case that inflammation of the tympanum and its membrane may
produce such a degree of deafness as that the watch cannot be
heard, even when applied to the ear.

In all probability the inflammation commenced and was ori-
ginally confined to the tympanal membrane, and afterwards ex-
tended to the middle, and, possibly, the internal ear.

From the latter stage of this boy's case we also learn a fact
worthy of observation, namely, that it is not the amount of vas-

s2

244 ACUTB MYRINGITIS.

cularity, but the degree of thickening and opacity in the mem-
brana tympani, which produces the deafness.

The next is a case of acute myringitis and tympanitis of one
pide ; and immediate recovery under the use of mercury.

C. L., a female, aged 21, applied at the hospital at ten o'clock
on the morning of the 18th of April, 1846, for an attack of
intense pain in her right ear. She states that she has not been
** regular** for the last six weeks ; that she was attacked four days
ago with catarrh, attended with considerable stuffing in her nose,
and the other usual symptoms of that affection ; that she had
walked along the sea-shore the day before, with a cold wind blow-
ing upon her right side. She went to bed tolerably well last
night, but awoke at three o'clock this morning with a violent
beating pain in her ear, accompanied by a loud noise, which she
likens to the '' puffing of a steam-engine f the pain resembles
that of a sharp instrument penetrating through her ear into her
head, which she describes as most excruciating. She had also
Bome pain and soreness over that side of the head ; she felt some
difficulty of deglutition, owing to the pain it caused her. Cough-
ing, sneezing, or any motion of the temporo-maxillary articulation,
greatly aggravated her sufferings, and gave her a feeling of bursting
in the middle ear.

She rose at seven o clock, felt great sickness of stomach, and
had a well-marked rigor whilst dressing. She immediately ap-
plied to a neighbouring practitioner, who put some ** drops** with
a piece of cotton into her ear, which only aggravated her symp-
toms. Her pain still continues, and the noise has increased;
there is slight redness and great heat of the auricle. The pain is
increased on making pressure over the tragus in front of the
meatus; on pressing or percussing the mastoid process slight pain
is also complained of. The pain in her ear, however, is not in-
creased by these means, nor is it referred to the tympanum. She
has no pain beneath the meatus, nor behind the angle of the jaw.
The hearing distance, with an ordinary ticking watch, is scarcely
three inches in the right ear. On closing the meatus of the left
side, the noise is greatly increased. On examination with a spe-

ACUTB MTBINGITIS. 245

Cttlum, the auditory canal is found highly vascular, dry, devoid
of cerumen, and exceedingly tender to the touch. The membrana
tympani has lost its polish, and is of a bright, florid, generally-
diffused red colour, spotted with small patches of a deeper hue,
like minute ecchymoses. The projection of the malleus can be
lecognised, of a darker colour than the surrounding parts, with a
whiush line in the centre. Below the malleus, and towards the
poeterior part of the membrane, a well-defined vesicle, about the
size of a grain of mustard seed, and filled with a brownish fluid,
can be seen. Upon holding the mouth and nose, and pressing
the air into the Eustachian tube, she experiences considerable
difficulty in making it pass up upon that side, while it passes with
facility into the tympanum of the left. The ear, or a stethoscope,
held to the right side during this operation, readily perceives, as
soon as the air reaches the tympanum, a squeeling and gurgling
sound, as if the air passed not only through a narrow passage,
but through a fluid- like mucus. This pressure of air into the
tympanum greatly aggravates her symptoms.

Upon looking into the mouth, the fauces, uvula, and back of
the pharynx are found nearly of their natural colour. Upon in-
serting the forefinger of the right hand into the mouth, and press-
ing its point upwards, backwards, and outwards, towards the mouth
of the Eustachian tube, considerable increase of pain is experi-
enced in the middle ear. The tongue is coated; the pulse re-
gular ; but there is heat of skin, and considerable anxiety of
countenance. The left ear is natural in function and appearance.
This patient suffered from rheumatism of the upper extremities
some time ago.

Four leeches were applied around the meatus, as far in as pos-
sible, and four in the depression in front of the tragus. She was
ordered to foment and steam the ear over hot water, placed in the
bottom of a long narrow mug, frequently during the day ; and a
purge was administered.

19th. States that she received immediate relief from the leech-
ing. The countenance is less anxious, and she slept well all
night; the noise of a steam-engine is altered to a gurgling sound;
the pain and all other symptoms are relieved ; the membrana

246 ACUTE MTRINQITI8.

tympani, however, remains nearly the same in colour, but the
vesicle has become flaccid. She was put on the use of calomel
and opium in small doses frequently repeated ; a blister was ap-
plied over the mastoid process ; the fomentation and warm vapour
was ordered to be continued, and a linseed-meal poultice to be
applied to the external ear at bed-time.

20th. Continues to improve. Noise changed to that of the
ringing of bells; the pain, on pressing the mouth of the Eustachian
tube, is much less; the membrana tympani is less vascular; the
general symptoms have all improved ; the mercury to be continued.

21st. All the symptoms relieved ; the mouth is slightly sore ;
no pain on pressing anywhere around the ear or meatus ; all heat
and vascularity of auricle is removed ; the membrana tympani has
lost its vascularity, but is slightly more opaque, and whiter than
natural ; the vesicle has quite disappeared ; three or four large
vessels can still be seen coursing along the handle of the malleus.
Upon forcing air through the Eustachian tube into the tympanum,
a slight gurgling noise can be perceived in the middle ear, and of
the peculiar sensation which it imparts the patient is quite con-
scious. During this operation, and while the membrane is within
the field of the speculum, a slight blush of redness, of a pinkish
hue, is observed to be produced in the membrane. The hearing
distance has increased to four inches. A copious red deposit was
observed in the urine. She has been slightly purged by the mer-
eury ; ordered to lessen its dose to one pill night and morning.

23rd. Continues to improve in hearing ; noise as before ; she
has had no return of pain in the ear ; the pain and soreness in the
head gone ; no flying pains or other rheumatic afiection ; the mouth
is very sore : ordered to omit the pills, and take the sixteenth of
a grain of oxy muriate of mercury with decoction and tincture of
bark three times a day ; generous diet.

25th. Continues to improve rapidly ; membrana tympani is
more transparent than upon last examinaUon. Hearing distance
is increased to twelve inches ; slight pain is still felt on pressure
over the lower portion of the mastoid process, and opposite the
point of the styloid process, in which latter place it is still increased
on coughing. Ordered to continue the oxymuriate and bark, and
to apply another blister.

ACUTB HTRINGITI8 WITH OTITIS. 847

All her symptoms have now disappeared, with the exception
of a slight buEzing occasionally; the hearing is perfectly restored^

Four months later I had an opportunity of examining this
youBg woman again ; her hearing had been quite restored ; but she
said that she occasionally suffered from a slight '* ticking noise."
The membrane of the drum upon the affected side presented a
dightly mottled appearance, particularly towards its lower edge»
bat without an opacity of any account; her hearing distance is
two feet less upon the right side than the left.

March, 1851. She had a slight attack of pain in the right ear,
accompanied by some deafness and redness of the membrana tym-
pani, all of which were at once removed by the application of
leeohes.

January, 1852. She has not had any return of pain or deaf-
ness; parts natural; hearing normal; no tinnitus.

nrFLAHHATION OF THE HEMBRANA TYMPANI AND OTITIS.

Case of severe rheumatic inflammation of the membrana tym-
pani and cavity of the tympanum, with periostitis, polypus, &c.

Mr. F., aged 49, with light hair and fair complexion, suffered
several years ago from a severe attack of rheumatism, in which his
heart was affected, caught while exposed to a cold wind upon the
top of a coach during a long journey ; since that period he has
been very liable to catch cold, in the head particularly, whenever
the feet are exposed to damp or low temperature. These attacks
of catarrh were characterized by violent fits of sneezing and run-
ning at the nose, &c. ; latterly his sense of smelling became greatly
impaired, and he perceived a stufling in the right nostril which
rendered him very uncomfortable. During the summer of 1846
he was attacked, in addition to the catarrhal affection, with cough,
expectoration, and other symptoms of bronchitis. Having reco-
vered from this, he remained in good health till January, 1847,
on the 28th of which month, during a period of very wet and se-
vere weather, his present attack commenced. His own words are :
** About this period I wore a muffler about my neck ; one sharp
morning I walked into my office, laid it aside on my arrival, and,

248 ACUTE MTRINOITIS WITH OTITIS.

being called off suddenly to the Four Courts, I forgot to put it on
again. On my way there I felt a blast of sharp, cold air strike
my throat on the right side, under the ear, but I did not pay much
attention to it, and remained in Court most of the day, with my
hat off occasionally. About two o'clock I felt a slight pain in the
light ear, and got a bit of cotton wool put into it ; about six o'clock
I returned home from my office. I called at my apothecary's, who
dropped some warm oil and laudanum into my ear, which, for a
time, lessened the pain, but did not completely remove it ; but I
was enabled to resume my business as usual next day."

Mr. Collins, to whom Mr. F. first applied, writes to me as fol-
lows : " When Mr. F. first called upon u\e he complained of pain
in his right ear, and also of slight shooting pains about that side
of the head ; he looked a little dull and heavy, but there was no
fever, quickness of pulse, headach, deafness, or other symptoms of
importance present. I considered his attack to be of a rheumatic
or neuralgic character, particularly as he had suffered a few years
before from severe rheumatic fever ; and as the pain in the ear was
what he most complained of, I dropped some tincture of opium
and olive oil into it, and applied a bit of wool to prevent its
coming out ; I also ordered him an aperient. Upon the next even-
ing Mr. F. again applied to me on his return from Court, and
stated that he had derived relief from the drops until he was again
exposed to cold and draughts that day : the drops were again ap-
plied and with relief. The next day Mr. F. resumed his usual
avocations, but the pain continued to increase, and four leeches
were applied behind the ear, and a poppy fomentation and a poul-
tice applied with considerable relief, though some slight pain still
remained in the ear and the side of the head. His sense of smell-
ing now returned, and continued perfect for a few days, when it
was again lost. Mr. F. confined himself to the house for the next
two or three days, but would not consent to do so longer, as he
felt much relieved of the pain, and business of great importance
required his attention at his office. In a few days from this date
his former symptoms returned, to relieve which he was strongly
recommended by a non-medical friend to drop into the ear a lini-

ACUTE MTRIHOITIS WITH OTITIS. 249

ment of oil of turpentine and oil of cinnamon, which I prepared
for him, but, having experienced no benefit from this, he applied
to you."

I first saw this gentleman upon the 13th February ; he com-
plained of acute pain in his right ear, which, as appears from the
foregoing account, had continued off and on during the previoofl
fortnight. The pain he described as '' shooting from the ear to
the temple and top of the head, accompanied with a boiling and
pumping noise, like that of a steam-engine ;^ the pain also appeared,
according to his own description, to reach to the throat, without
making the throat sore ; it was increased by sneezing, but relieved
by pressing the hand upon the ear and side of the head. The
auricle was hot and somewhat swollen ; the lining of the meatus
and auditory canal was red, tumid, and completely devoid of ce-
rumen ; the introduction of the speculum, and the examination,
caused a good deal of pain from the tenderness of the parts ; the
membrana tympani was of a dark, brown-red colour, had lost its
polish, and appeared to be swollen and pressed outwards : the pro-
jection of the malleus could not be discerned ; pressure in firont of
the ear gave a good deal of pain, but there was no tenderness over
the mastoid process. Rest, abstinence, confinement to the house,
constant fomentations, leeches round the meatus, with small doses
of blue pill, James's powder, and hy oscyamus, at night : and an
aperient in the morning, was the treatment resorted to during the
next few days.

Upon the 19th, his symptoms, with the exception of the pain
in the ear, continued much the same ; he had also flying pains of
a rheumatic character in the side of the head, the wrists, feet, and
generally throughout the body. The pumping and boiling noise
remained unabated : the deafness now became complete upon that
side. The appearance of the ear continuing unchanged, except
that the meatus was more swollen, it was deemed advisable to place
him under the influence of mercury, — an opinion in which Dr.
Stokes, who saw him with me, at that time concurred. He was ac-
cordingly, but with some difficulty, mercurialized by means of
small and frequently repeated doses of blue pill, calomel, and
opium. When his mouth became sore, the pain in the ear and

S50 AOUTB KTBHraiTtS WITH OTITIS.

the noise lessened somewhat^ and the general rheumatic affection
disappeared ; but the meatus and auditory canal now became so
much decreased in caliber, owing to the thickening of the lining
of these parts, that it was not possible to gain more than a glimpse
of the red and swollen membrana tympani. The leeching and
blistering were continued, and the surfaces denuded by the latter
Were dressed With extract of belladonna and mercurial ointment.

March 10th. The cuticle became detached, and a slight mu-
oo'pilfalent discharge took place from the external meatus ; the
ear was then syringed with plain tepid water ; he was allowed a
mote generous diet, and placed upon the use of the hydriodate of
{k>tash, with infusion of bark and tincture of orange peel. His
general health now improved ; he slept better, and was able to go
abroad and take exercise ; the discharge, however, continued to
increase, and emitted a very offensive odour ; and^ at the same
time, he began to complain of a deep^eated soreness all over the
(dde of the head, behind the ear, but particularly over the mastoid
process and immediately below it. Towards the end of March,
upon examining the ear carefully under a good light, a small po-
lypoid excrescence of a light red colour, growing from the poste*
nor wall of the canal, and completely filling up that cavity, was
detected ; this I removed with the wire snare, and the discharge
then lessened ; the soreness of the side of the head, the pumping,
and the deafness, however, remained the same. Pressure over the
mastoid process and the post-aural region of the head, very much
increased the soreness, and it was now evident that the periosteum
covering these parts was inflamed.

During the latter part of the month of April, and all the month
of May, the symptoms of periostitis remained much the same, and
the scalp itself became inflamed, having a dusky, red hue, pitting
on pressure, and feeling excessively sore to the touch. The treat-
ment consisted in the frequent abstraction of blood from the af-
fected part by means of a few leeches, and a small cupping-glass
applied over the leech-bites ; poulticing, inunction with different
ointments, both of a sedative and absorbent nature, slight vesi^
cants, &c., and change of air. Bark, potash, and iodine were also
taken with a view to improve the general state of the constitution.

ACUTB MTRINGITIB WITH OTITIS. 251

He had no headach, rigors, or perspirations, and his sleep and ap-
petite were tolerably good ; still, however, the pain continued, and
the dusky redness and tumefaction of the scalp remained, although
there was no evidence of suppuration. It was determined, in con-
sultation with Mr. Cusack, to make an incision down to thebone»
and thus free the periosteum, and give exit to any matter which
might be contained beneath it. Accordingly, upon the 29th of
May, I made a perpendicular incision, about two inches long,
nearly parallel with the posterior margin of the auricle, by insert-
ing a sharp-pointed scalpel down to the bone at the point of in^^
sertion of the mastoid muscle, and carrying it upwards and a little
backwards. The bone did not feel rough or gritty under the knife.
A pledget of lint was inserted into it ; and when the haemorrhage
had ceased, a llnseed-meal poultice was applied over it. The wound
suppurated kindly, and all the surrounding soreness of the scalp
and pain on pressure soon disappeared. As the discharge from
the wound increased, that from the meatus lessened, and in about
ten days the wound itself healed without any exfoliation of bone.
The pumping noise now ceased altogether, the discharge from the
ear also lessened very much, and all uneasiness in the parts ceased.

During the month of July, and till the 12th of August, I only
saw Mr. F. occasionally. Upon examining the ear carefully at
this latter date, I perceived that the meatus had regained its na-»
tural size, and I discovered another second small polypus in the
situation of the first ; this I also removed, and Mr. F. came to me
in a day or two to inform me that the discharge had now ceased
altogether, and that the hearing had returned the night after I had
extracted the polypus. He could now perceive the ticking of a
watch at the distance of an inch from his ear, although he was
quite unconscious of it when pressed against the auricle the day
I last saw him. I could now distinguish the membrana tympani
perfectly ; it was of a dull white colour, evidently much tUck-
ened, but not perforated in any part.

September 3rd. He has continued to improve in every respect ;
his health and spirits are quite restored ; all discharge from the ear
has ceased ; the tinnitus aurium now consists in a slight '* booing**
which appears occasionally : the hearing is slowly returning.

252 ACUTB HTRnrams with otitis.

The snuffling and loss of smell I now found to be caused in a great
measure by a small gelatinous polypus which filled up the cavity
of the right anterior naris, upon removing which, both the nasal
respiration and the sense of smell were much improved.

This case is instructive, as showing the rheumatic character of
some of the inflammations of the ear, and as exhibiting the occa-
sional failure of the mercurial treatment to cut short the disease,
particularly if it has advanced to any height, as this had. The
discharge came from the external ear and the polypus. This mor-
bid polypoid growth, thus appearing during the progress of an
inflammation, should always lead the practitioner to suspect mis-
chief going on in the neighbourhood, and should cause him to ex-
amine with great care the condition of the mastoid process and its
coverings, although neither the exbtence of a polypus, nor the
foDtor or dark colour of the discharge, are of themselves a suffici-
ent proof of caries or denuded bone. The appearance of perios-
titb, even at this late period, is not an unusual consequence of
violent otitis ; the inflammation may spread from the periosteum
lining the bony portion of the meatus ; or the mastoid cells may,
and often are, the seat of inflammation, and this inflammation may
extend from the layer of bone which covers them to the perios-
teum. If not relieved by such local and general means as were
made use of in the early part of the foregoing case, the surgeon
should not hesitate to cut down upon the covering of the bone,
and divide it fairly for an inch or more of its length. Almost im-
mediate ease follows this operation, even though we fail to disco-
ver the existence of pus ; and, moreover, delay after a certain period
may prove fatal. A thin shell of bone is occasionally thrown off
in such cases, but not always. Generally speaking, the otorrhcea
lessens when the discharge from the wound is fully established,
although there may not be any communication whatever between
the parts from which these discharges come. When this pain over
the mastoid process appears early in the disease, and is accompa-
nied by an erysipelatous redness and cedema of the scalp, we should
not hesitate in having recourse to incision immediately.

We have in this case another remarkable example of a mecha-
nical impediment, such as the polypus, so completely obstructing

8UB-ACUTB MYRINGITIS. 253

sound, that a watch held to the ear was not perceived, although
hearing returned within a few hours when that mechanical obstruc-
tion was removed. There can be little doubt of the middle ear
having been engaged in this inflammation, yet we have no evi*
dence of perforation of the membrane of the drum having taken
place. The only treatment subsequently employed with Mr. F.
was that of occasionally washing over the auditory canal and mem-
brana tympani with a solution of nitrate of silver.

SUB-ACUTE MYRINGITIS.

Besides the acute form of the disease, attended by violent pain,
&c., already described, there is a description of sub-acute inflamr
fncilion'* of the membrana tympani, with which I have been long
familiar, and which, although perfectly painless, is equally destruc-
tive to hearing. It generally appears in persons between 15 and
30. The first symptom to which the patient s attention is directed
is deafness, which has appeared rather suddenly. It may be, but is
not necessarily, accompanied by tinnitus ; but there is always a feel-
ing of stuffing in the ear ; the same stuffing is felt in the nose and
frontal sinus ; the patient complains of there being a veil between
him and the sound. The tympanal cavity is usually free ; and
when it is not, blowing the nose or sneezing sometimes suddenly
restores the hearing : and this is one of the causes why the disease
is so frequently neglected, the patient expecting a similar effisct
from day to day. The nature of the disease is only to be learned
by a careful inspection of the membrane, which, if we see the dis-
ease early, is always of a pink colour, of a tint somewhat paler than
that of the monthly rose. Through this, dispersed in various di-
rections, we may observe in some cases a few long, tortuous vessels.
The transparency and polish of the membrane are seldom much
affected at first. The auditory canal does not usually exhibit signs

* Dr. Kramer has, in the latest edition of his Ohrenkrankheiten^ foand mach faalt
with my classification of the inflammations of the membrana tympanL Upon a carefb]
revision of my opinions, and five years' additional experience of these diseases, I see no
reason to discard any of the forms of disease which I originally published, although the pre-
sent arrangement is somewhat different Had Dr. Kramer accustomed his eye to distin-
guish the different ophthalmic inflammations, he might have been able to appreciate the
various shades of colour on the membrana tympani.

254 SUB-ACUTS MYBINGITIS.

of disease, but the cerumenous secretion is arrested. Generally
speaking, there are no constitutional symptoms present, and when
tinnitus is an accompaniment, it is usually of a very light charac-
ter, resembling a slight buzzing or singing. If allowed to proceed
unchecked, the membrane becomes thickened and remarkably
opaque, from lymphy deposits, and the deafness which ensues is
of a most irremedial nature. Collapse or drawing inwards of the
membrana tympani does not usually follow this form of the affec-
tion, but ulceration, even to perforation of the membrane of the
drum, is not an uncommon attendant upon it.

This disease is slow in its progress, and requires very careful
watching. Cases of this nature have been, I feel convinced, re-
peatedly treated as '* nervous deafness.** I am inclined to think
that it is a true myringitis, in which the inflammation is seated
in the fibrous layer of the membrane. In this disease mercury is
just as necessary as in that already detailed ; it should, however,
be given after a different fashion : to be effectual, it must be slowly
introduced into the system, so as to produce a steady and gradual
effect. The mouth should be kept sore until there is a decided
improvement both in the vascularity and in the hearing, or until
all hope of restoration has been abandoned, or other circumstances
induce us to relinquish this mode of treatment. After the consti-
tution has been fully affected by the mineral, the bichloride, given
in doses from the sixteenth to the eighth of a grain, dissolved in
proof spirits, and taken in half an ounce of the cold infusion of
bark, and a scruple or half a drachm of Huxham*s tincture, three
times a day, will be found highly efficacious. The preparations
of iodine are also, in the advanced stages of the disease, worthy of
trial ; but I do not think that the preparations and combinations
of iron produce in aural inflammations the same benefit which they
do in constitutions labouring imder ophthalmic affections of alike
character.

Counter-irritation over the mastoid process, change of air, re-
moval to the sea, and generous living, will hasten the cure.

To relieve tinnitus aurium, after the inflammatory action has
been subdued, or the original disease which produced it has sub-
sided, and particularly in cases where we find this symptom pre-

SUB-ACUTB MYRINGITIS. 255

sent without any apparent lesion of the parts we are able to in-
spect,.! have found the preparations of the Arnica montana of de*
cided benefit ; indeed it is the only medicine with which I am
acquainted that seems to possess a specific power over this an-
noying and usually most intractable complaint. The preparation
I find most efficacious is the tincture both of the flowers and
leaves, of which the patient should commence by taking fifteen
drops in a table-spoonful of the infusion of Arnica, with some cor-
dial tincture three times a day. After a few days the dose should
be increased one or two drops daily, till it reaches thirty, or even
more, unless headach or giddiness be produced, when we should
at once lessen the dose, or omit the medicine altogether for a short
time.* The state of the bowels should be carefully attended to
during the administration of this drug.

So long as any vascularity or recent deposit exists in the raem-
brana tyrapani, notwithstanding manifest improvement of the
hearing, we should not desist from employing means to remove
it, as these cases are of a most insidious and protracted character.
When ulceration exists, we should touch the part daily with a
solution of lunar caustic, applied with a fine brush.

In all the inflammations of the middle and external ear, the
secretion of cerumen is arrested, and it is long aftier the disease has
been relieved, that the cerumenous glands resume their healthy
functions, the auditory passage remaining dry and its lining scaly :
or the wax which is produced being insufficient in quantity, of a
very dark colour, and soon becoming hard and inspissated. This
deficiency of cerumen, which is but a symptom, is often set down
as a disease, and various applications, such as ox-gall, creasote, gly«
cerine, &c., have been recommended to restore it. I find, how-
ever, that nothing produces a healthy action in the parts so soon,
while, at the same time, it immediately supplies the best artificial

* The folloiving is the formula for the tincture: — One ounce and a half of ih^flower$
to a pint of rectified spirit of wine ; macerate for fourteen days and strain ; or, of the
leaves^ the same quantity infused for a similar period in proof spirits. In prescribiiv
these I usually order them in equal proportions.

Dr. Neligan says : ^* This tincture may be readily prepared by percolation, haring
preTiously macerated the flowers with a little of the spirit for twenty-four hours ; or it
may be prepared with the cat and bruised root in the proportloa of Sii. of the root to Qj.
of rectified spirit. Dose, £ 3flB. to f. ^iJ'—MtdimMt and thtw Uu9>

256 SUB-ACUTB MTBINGITIS.

saccedaneum, as the soft brown citrine ointment, applied to the
auditory passage in a melted state with a soft brush.

The following case affords a good example of the sub-acute
form of the disease, of the inattention paid to the early symptoms
of deafness by practitioners in general, and the ef&cacy of anti-
phlogistic treatment. As the subject of this case, Mr. S., then
aged 19, was a gentleman of very great intelligence, I give the
history of his case, as far as possible, in the words of the narrative
with which he has furnished me : ** About the year 1836 I felt
symptoms of deafness in both my ears for the first time, but on
the application of blisters these symptoms passed away. From
being but a child at the time, I have an imperfect recollection of
the peculiar symptoms of my case. Again, in 1840, I became
quite deaf in my right ear: this I mentioned to our family physi-
cian, but for some time he treated it as a joke, telling me merely
that I was idle and wished for some holidays; however, on my
frequently asserting that I really was deaf, he directed me to
syringe my ear night and morning, and afterwards he dropped
some liquid into it which he prescribed for me, but he did not
make any particular examination of my ear. I continued to fol-
low his advice for some weeks, but without any beneficial effect.
I was then advised to get some rusty bacon, cut it into small
shreds, and put one, morning and evening, into my ear, — but with
no better success.* At last I applied a blister behind my ear,
and kept it open for six months. This treatment, which may,
and very probably would, as experience has since shown me, have
been successful, had it been resorted to in the first instance, was
then of no avail. On two subsequent occasions, about Christmas,
1841, and July, 1842, 1 had an ear-ache in that ear, and the only
application which gave me relief was dropping warm laudanum .
into it-t At the close of September, 1845, I felt my left ear one

* This is a very popular remedy in Ireland, and is frequently prescribed by medical
practitioners. In cases of deafness solely the result of a deficiency of cerumen (very rare
cases, by the way) it is innoxious, and may be effectual, but in no other case that I am
aware of is it at all applicable.

f Laudanum dropped into the ear is one of the most popular remedies for ear-ache,
and in many instances it affords reliefl I do not object to its application as a means of
lessening pain, but I do as a remedial agent, while the eaute of the pain is uninvestigated,
and not treated according to the estabUdied mlea for lessening inflammation, &c.

SDB-ACUTB MYRINGITIS. 257

morning as if it were stopped, and perceived a buzzing sound in
ity such as one feels on applying a sea-shell to it. This noise was
increased at night when I lay in bed ; it then resembled a constant
loud hissing. I became very deaf, and my difficulty of hearing
increased daily ; I also experienced an uneasy sensation, and a
feeling of stuffing, in this ear, but no pain."^

On the 21st of the November following I first saw this young
gentleman. I found, in additioh to the symptoms already de-
scribed, a bright pink hue diffused over the left tympanal mem-
brane, which, however, had not lost its polish, nor become opaque.
He was with difficulty able to inflate the drum, and when he did
so, the stream of air caused a slight squeeling and a mucous
gurgling in the middle ear. The external meatus on both sides
was dry, devoid of cerumen, and somewhat redder than natural.
The throat was normal. It was evidently a case of sub-acute in-
flammation of the membrana tympani, of the mucous membrane
lining the cavity of the drum, and the Eustachian tube : with mu-
cous engorgement of the middle ear. Upon the right side the mem-
brana tympani was thickened and opaque, and two or three large
red vessels spread over its surface, but the air passed up with fa-
cility. Six leeches were immediately applied to the left ear, three
round the meatus, and three in front of the tragus, and warm stupes
and fomentations prescribed.

Upon the 29th his symptoms remained unabated and the ap-
pearances unaltered, so I immediately put him on the use of mer-
cury ; and at the same time a repetition of the leeches round the
meatus, and the application of blisters over the mastoid process,
was had recourse to. As soon as the mouth became slightly af-
fected, I observed that the vascularity of the right ear — that
originally affected — was very much lessened, and I then recom-
mended the application of leeches and blisters to that also ; and
had the satisfaction to find, that the hearing began to improve
gradually on this as well as on the left side.

As Mr. S. improved daily the mercury was omitted, and he
commenced the use of bark and hydriodate of potash. Towards
the end of December he was so much improved that I disconti-
nued my attendance, and I lost sight of him for a short time. In

T

358 SUB-AOUTE MYRINGITIS.

the beginning of January, 1846, however, he again applied to me :
worse than ever. The weather had been remarkably damp and un-
favourable ; he was much exposed to its influence, and had caught
cold, which, to use his own expression, had *^ pitched in his ears.'*
He was then so deaf that he could with great difficulty under-
stand what was said to him, although addressed in a distinct and
loud voice. The vascularity had returned in the left, and partially
in the right ear, and the mucous engorgement of the tympanal ca-
vities was more manifest. The same course had to be pursued
as on the former occasion ; he was confined to the house for a
month, and kept under the gentle influence of mercury for the
last three weeks of that time. I desired him to try occasionally
to press the air into the drums, particularly when blowing the
nose ; and as the inflammatory condition subsided he was enabled
to do this with greater facility. Each time tlieair passed, his
hearing was improved. At the end of a month the mercury was
discontinued and the leeching given up. Small blisters were
kept open behind the cars, and the use of bark and hydriodate of
potash was persisted in for some weeks longer. In the following
November all trace of disease had been removed from the left
ear, and the tympanal membrane of the right was much thin-
ner, and much less vascular and opaque, than when I first saw
him in 1845; — his hearing was perfect upon the leftside, and in-
creased on the right to fourteen inches. He has remained well
from that time to the date of the publication of this work.

In the foregoing case we have a good example in the right
ear, — which, when I first saw it, was in the condition of chronic
inflammation, — of the eflects of neglect, and also of the efficacy
of the mercurial and antiphlogistic treatment, not only in the re-
moval of recent disease, but in the improvement of an afiection of
several years' standing.

I could enumerate several other well-marked cases of this dis-
ease, were it necessary, all presenting the same appearances, and
cured by the same means, but in very few has treatment been
attended with the same happy results in an ear so long afiected
as in this. Generally only one ear is affected at a time, but
sooner or later the other usually becomes engaged. I feel con-

8TPHIUTI0 MTRIVOITIS. 259

vinced that many cases of incurable deafness have arisen from
this disease.

In the treatment of the malady, the efficacy of tobacco-smoke
should not be omitted. Where there is redness and relaxation of
the mucous membrane of the throat and nose, with much *' stuf*
fing in the head," and mucous engorgement of the middle ear, the
moderate use of tobacco-smoke inhaled from a good cigar, and
gently puffed out through the nose, will be found beneficial. It
certainly acts as a stimulant and astringent on the surface with
which it comes in contact, and it is not improbable that some of it
may find access to the cavitas tympani. I understand soldiers are
in the habit of forcing tobacco-smoke into their ears when they
become deaf. In strumous myringitis, and also in chronic or sub-
acute inflammation of the lining of the tympanum, tobacco-smoke
is often of service.

SyphUitio MtfringiHs. — Although practitioners who treat sy-
philitic diseases upon a large scale appear to be aware of the
fact, that venereal occasionally causes deafness, I cannot find any
authority which has noticed the disease I am about to describe*
The deafness which sometimes accompanies the secondary form
of syphilis is generally believed to be caused by inflammation
and ulceration extending from the throat through the Eustachian
trumpet into the middle ear; such may, imder certain circum-
stances, no doubt, occur, and produce destructive inflammation
and suppuration in this cavity, although I have never seen such
a case myself, nor have I met with a well-authenticated instance
of it recorded. The English writers upon aural diseases have
altogether omitted syphilitic affections of the ear, as have also
Kramer and most of the continental writers, with the exception
of Lincke and Frank, the latter of whom enumerates two forms, —
the first, external syphilitic otitis, in which secondary ulcerations
occur in the auditory canal, accompanied by other well-determined
symptoms of the disease; but these are already known to the sur«
geon, they resemble ulcerations on the margins of the tarsal car-
tilages, and are sometimes the consequences of rupia upon the
auricle, in the vicinity of the meatus (see page 169). Under the
head of otitis interna, he describes the result of lues, which, he

T 2

260 SYPHILITIC MYRINGITIS.

says, arises either as a reflex of the disease in the ear itself, or is
propagated through the Eustachian tube from the throat. He
says this dbease is accompanied by great pain, and often termi-
nates in suppuration of the middle ear, destruction of the tympa-
nal membrane, and caries of the temporal bone. It is evident,
however, from his description, that the disease of which he speaks
is the ordinary suppuration of the cavity of the tympanum, with
s neglected otorrhosa, and in nowise characterized by any peculiar
syphilitic symptom.

Lincke's usual accuracy and observation seem to have deserted
him when writing his chapter upon ** Otitis Syphilitica \ for, while
the affection now under consideration seems totally to have es-
caped his observation, he has, with most laborious German assi-
duity, collected together a multiplicity of authorities bearing upon
the subject of what are supposed to be syphilitic diseases of the
ear, but not one of which he himself has verified. Thus he enu-
merates from the works of CuUerien and Plisson chancres both on
the auricule and in the meatus. He also gives a description of
chancres, *' if they arise near or on the membrana tympanV' ! but,
like Frank, his descriptions are chiefly in reference to the syphi-
litic otorrhoea, the result of inflammation and ulceration extend-
ing from the throat or nose, a disease, the existence of which yet
remains to be proved by original observers, not system-makers or
cyclopaedia-compilers.

While Lincke's work must ever remain a most valuable book
of reference, it is high time for those who wish to advance the
science of aural surgery to cast off* the incubus of authority, and
by patient investigation and originality of observation to establish
facts. Kramer deserves much more credit for omitting all notice
of an affection which it is evident he had never himself observed,
than those writers who, with equal want of knowledge, have en-
deavoured, by collecting out of a variety of obscure writers some
ill-recorded cases, to establish an untenable theory.

In 1835, M. Lallemand, in his Clinical Lectures on Syphilitic
Diseases, as reported by Dr. Waters, related four cases of syphilitic
deafness cured by ante-venereals. (See Medical Times, for 27th
September.) Were medical literature to be searched from end to

8TPHILITIC MTBIN0ITI8. 261

end, I do not think such instances of unwarranted assertion and
loose writing could be found. The state of the membrana tym-
pani was never inspected, nor the condition of the middle ear ex-
plained, in any one of these cases.

The disease which I am about to describe is an inflammation
of a specific character, occurring in the membranes of the tym-
panal cavity, but chiefly exhibited in the external membrane of
the drum. All the cases I have seen of this affection occurred in
young men, and generally those of fair complexions and blue
eyes, who had had primary sores upon the genitals from six to
twelve months previously, which sores were of rather a deceptive
character, so that mercury was seldom given in the first instance,
at least in a legitimate form. These sores were usually tedious in
healing, and followed by papular eruptions and sore throats, for
which mercury was, in most of the cases, taken irregularly. Bu-
boes were not a common attendant, nor had iritis ensued in any
of the instances of well-marked venereal myringitis which fell un-
der my notice ; but, generally speaking, eruptions, copper-coloured
blotches, fissures and ulcers of the tongue, with loss of strength,
and slight nocturnal pains, existed previous to the aural afiec-
tion, which should, I think, be ranked as a tertiary symptom.
In almost every case which I have witnessed, the disease appeared
suddenly, as an eruption was fading ofi*; in two, it came on at a
later period, and was accompanied by loss of hair; in most it ap-
peared in the upper or middle ranks of life. In some cases there
is at first a sensation of fulness in the head, and often vertigo
upon stooping or rising up suddenly, and the patients have usu-
ally a feeling of fulness within the ear; but in no instance have I
seen it accompanied by acute pain, in which circumstances it re-
sembles the sub-acute form of inflammation already described, and
is therefore placed as a subdivision of that species ; but upon in-
spection, the amount of redness and vascularity will be found very
much greater than the latter; and in this consists one of the chief
characteristics of this disease, that while it is unaccompanied by
local pain, as in the sub-acute inflammation, the membrana tyra-
pani will be found to present an amount of redness equal to, and
sometimes exceeding, that seen in acute myringitis. The redness

262 STPHIUTIC MTBIHQITIfl.

has generally, howemer, a brownish hue in the syphilitic form,
which is not observable in that just alluded to. There is not, at
first, much loss of polish, but in a short time the membrane as-
sumes a fuzzy appearance. The auricle and meatus I have not
seen affected more than in the sub-acute form ; both ears are usu-
ally attacked at the same time. The amount of deafness is always
very great, and is the symptom that first attracts the patient's at-
' tention, and it seldom varies. Tinnitus is not usually present, but
in two cases which I possess the notes of, the deafness was ushered
in by a very loud noise, which passed away after a few days.
This inflammation does not end in muco-purulent discharge
from the tympanum, the surface of the membrana tympani, or
the sides of the auditory canal ; nor have I seen lymph effused
upon the membrane, as in the more violent and painful forms of
otitis ; but from its brownish-red colour in the very early stage*
from a yellowish speckled opacity, which is generally observable in
it on the subsidence of the redness, and from the intense degree of
thickening and dulness which were present in some cases, which
were evidently the result of syphilitic disease, I am inclined to
think that lymph is largely effused between the laminse, or upon
the inner surface of the membrana tympani. Two of the worst
' cases of non-congenital deafness I ever saw appeared to have been
the result of syphilitic inflammation, and in both there was great
thickening, opacity, and insensibility of the membrane. I am also
inclined to think that syphilis has played a more extensive part
in the production of deafness than the profession is aware of.

The following case of syphilitic inflammation of both tympa-
nal membranes, with rapid recovery under mercurial treatment, is
characteristic of the affection.

Mr. A. B., aged 30, had a doubtful-looking sore upon the
penis, twelve months previous to my seeing him. Considerable
doubt was expressed as to the genuine syphilitic character of the
Bore ; but it healed under local treatment. Some months subse-
quently he had a bubo in the right groin, and a small abscess also
formed on the under side of the urethra ; he then rubbed in mer-
cury, and was confined to the recumbent posture, until the swell-
ing of the groin had completely subsided. After tiiis he expe-

SYPHILITIC MrrRINGITIS. 283

rienced great weakness and lassitude, and suffered for several
weeks from sore throat. These symptoms were relieved by re-
moval to the country ; but on his return to town, an eruption ap-
peared extensively on the genitals, thighs, and abdomen, and he
had also some slight deafness. He was benefited by the use of
hydriodate of potash ; but the eruption came and went, both on
its original seat and on the chest and extremities, during the next
few weeks. I first saw him with Mr. John Evans, in the middle
of October, 1847 ; he had then no sore throat, but a fresh crop of
eruption, in the form of brownish spots interspersed with small
pimples, had appeared generally over the back and the outer sides
of the arms. He had also become exceedingly deaf, hearing the
watch only when pressed against the auricle, and he complained
of a sense of giddiness and fulness in the head, but had no pain
whatever in the ears, nor any snuffling in the nose. He stated,
that his deafness had occurred suddenly, a few hours after rising
in the morning some days before ; that he had tinnitus at the com-
mencement, but that it had now nearly vanished. Upon inspec-
tion, the auditory canal was found dry, and the membrana tym-
pani of an uniform dark brown-red colour, so that the situation
of the hammer bone was not easily recognisable. There was no
ulceration observable, nor any alteration in the plane of the mem-
brane : but the light was not reflected from it in the ordinary
manner, thus showing that it had lost its polish. These appear-
ances were nearly the same upon both sides. He was able to in-
flate the drums perfectly, and auscultation afforded no evidence
either of contraction of the audito-faucial passages, or of any accu-
mulation of fluid within the tympana.

The treatment consisted in the application of leeches round the
meatus every second day, and the use of calomel and opium in
small and frequently repeated doses. This mode of administering
the mineral disagreeing, we were obliged to discontinue it, and
substitute inunction in its stead. The deafness and the appear-
ance in the ear remained unaltered until the morning on which
salivation was produced, and then hearing was restored almost mi-
raculously, and the next day the redness and vascularity in the
ears had almost disappeared. Gentle pytalism was kept up for

264 SYPHILITIC MYRIHGITIS.

some days longer. He has not since had any return either of the
deafness or other syphilitic symptoms.

I attended a case with Mr. Cusack some years ago, in which
it was found necessary to keep up the mercurial action for above
a fortnight, but in that instance the disease had been of much
longer standing ; I also treated a well-marked case in consultation
with Mr. Mason, in which several relapses occurred, just as we
often observe in syphilitic iritis.

Case No. 4 in the Registry presented syphilitic inflammation
of the membrana tympani on both sides.

P. L., aged 30, a policeman, with fair complexion, light hair
and eyes ; has complained of deafness, unattended with pain, for
one month; says he had a primary syphilitic sore about three
months ago, and lately suffered from sore throat; has slight copper-
coloured patches upon the skin of the forehead, but does not exhi-
bit symptoms of any other eruption. He has ulceration of the soft
palate, a deep excavation, with a yellowish ash-coloured slough
coating its bottom, existing on each side of the uvula. He did not
get mercury for the original sore. The deafness came on in both
ears about the same period, and occurred during the daytime.

Left Ear. — Meatus dry, polished, of a grey colour, and totally
devoid of cerumen. The tympanal membrane shows an exceed-
ingly well-marked sub-acute inflammation ; there is a pinkish hue,
like that of a rose-leaf, all over it, but it still preserves its polish,
and has not become collapsed or altered in shape: a tolerably
well-marked crescentic opacity margins its inferior attachment.
The patient can inflate the drum, and thereby render the vascu-
larity of its external membrane more intense, and of a darker red ;
he has a singing noise in this ear, and only hears the watch when
pressed against the auricle.

Right Ear. — Meatus paler, more polished and opaque than on
the left side. The tympanal membrane is redder, and also some-
what collapsed, so that the malleus projects very prominently.
Has an intermitting noise in character like that experienced when
a conch-shell is held to the ear. Cannot fully inflate the drum on
this side, but the effort to do so renders the membrane of a deeper
colour. Cannot hear the watch on this side.

SYPHILITIC MYRIM0ITI8. 265

A pill of one grain of calomel, two of blue pilli and a quarter
of a grain of opium, was ordered to be taken three times a day.

30th. In this case the mercury has acted fairly and legitimately,
and we find that the disease for which it was administered has al-
ready given way. In the right ear the pinkish colour of the drum-
head is very much lessened, the polish has been in part restored,
and the patient says that the singing noise has greatly decreased.
He now hears the watch when applied to the ear. Upon the left
side all the symptoms have improved, and the hearing distance has
increased about twcinches. If we apply the watch to the ear and
then draw it slowly from it, the deaf person will be able to catch
the sound (the ear appearing to retain the impression of the tick-
ing) at a somewhat greater distance than if we approached the
watch to the ear.

The mercury was lessened to one pill night and morning, and
directions were given to the patient to decrease it still further if
the mouth became sorer. The ulcers upon the soft palate, which
have assumed a more healthy aspect than before, were brushed
over with a strong solution of nitrate of silver.

February 1st. — This patient is greatly improved in every
respect; hearing increased on both sides. Upon the left, the tym-
panal membrane is much paler than at the time of the last exa-
mination, and the noise completely ceased in this ear upon the
previous day, without the man being conscious of any crack or
sudden sound at the time of its cessation. Upon the right side
the membrane has improved in colour and gained more polish.
The ulcers in the throat have thrown off their sloughs, and pre-
sent a healthy appearance ; the mercurial action upon the mouth
is still manifest. The dose of the mineral to be decreased to one
pill daily.

5th. A still further improvement has taken place since last
report. Upon the right side the membrane is yet slightly pink-
ish ; the hearing as before. Upon the left side the membrane has
greatly improved, and is now nearly of a natural colour ; hearing
distance seven inches ; throat healthy ; mercurial action still ma-
nifest. Ordered four grains of hydriodate of potash and one drop
of tincture of iodine, to be taken in decoction of bark three times
daily.

266 OOUTT OTITIS.

9th. Grencral health and appearance much improved. Mer-
curial action scarcely perceptible ; but the gums are still slightly
retracted beneath the lower incisors, and exhibit a red, pulpy mar-
gin. The ulceration of the throat has quite ceased, and the ca-
vity upon the left side is nearly filled up. Ue says his hearing is
completely restored, but the noise comes on occasionally in the
right ear. Upon this side there is some secretion of cerumen upon
the posterior surface of the meatus. The tympanal membrane is
still slightly pinkish, but bright, thin, and polished, reflecting the
light from its lower convex portion. He can inflate the tympanum
with facility, and upon applying the stethoscope over the meatus,
while the patient presses the air into the ear, a slight gurgling
noise can be perceived as it reaches the cavity of the middle ear,
which, in all probability, contains a quantity of mucus, exuded
from its lining membrane during the inflammatory process, which,
there can be little doubt, extended to it and to the lining of the
Eustachian tube, — parts that we cannot see, — as well as the tym-
panal membrane, which we can see. On the left side : hearing dis-
tance ten inches ; meatus still red, shining, and devoid of cerumen ;
tympanal membrane opaque, but thin and polished ; a couple of
large red vessels traverse along the insertion of the malleus. The
air does not reach the cavity of the middle ear so well as upon the
right, and it has a more squeeling sound, probably arising from the
thickened membrane and the decreased caliber of the Eustachian
tube. Ordered to continue the iodide of potassium, and to apply
small blisters behind the ears occasionally for the next fortnight.

That Gouty Otitis may exist I have no doubt, but I myself have
never seen a well-marked example of it ; neither have I yet read
a description of that disease which afforded any one pathognomic
which could be relied upon. I have, at page 168, alluded to
attacks of gout in the auricle : Dr. Graves, to whose authority
I there referred, gives an instance of deafness attended with
otorrhoea, in which the patient's hearing was always improved
afler a seizure of gout in the foot. Several continental authors
mention gout as a cause of deafness and disease of the ear : — Dr.
Vering of Vienna, in 1832; Lincke in 1840; and Frank in 1845 ;
but they are chiefly compilers, whose writings on some points re-

THS D1AFHB86 OF OLD AGE. 267

mind one of the variety of counts introduced into an indictment
in the hope that some one of them may convict the prisoner.
Within the last few months a special work has appeared on the
subject, — that referred to at pages 49 and 225 ; but I cannot dis-
cover in it the requisite information, as the symptoms of the diffe-
rent forms of gouty otitis therein detailed are common to every
other form of aural inflammation. The author, Mr. Harvey,
says that " furuncles form and burst in the muscles* of the ears."
Next follows otorrhoea, which, if of long duration, may produce
polypous growths. In frequent relapses ** varicose vessels become
develc^d on the membrana tympani," and when the disease proves
fatal from what may be termed cerebral otorrhoea, '< all the canals
are found to be filled with purulent matter, as well also the cells
of the mastoid process, the bone itself being in a state of caries.**
Now, when gout seizes upon the eye, it chiefly affects the sclerotic
and the iris, and I would expect from analogy that where it was
seated in the ear, its manifestation would be in the fibrous layer
of the membrana tympani, in the form of acute myringitis, like
that seen in rheumatic cases.

Some time ago Mr. Toynbee published a small tract, with the
attractive title of " The Pathology and Treatment of ^ Deafness
attendant upon old Age^ in which the author successfully combats
the conclusion to which medical men have arrived, that deafness
" depends upon a gradual and natural decay of the powers of the
organ of hearing, and that it must in consequence be endured as
a disease entirely beyond human control.** And the result of the
author's experience tends to show that the decline of audition '^ is
dependent upon the influences to which aged persons are fre*
quently subjected : namely, the prolonged stay in warm rooms,
the avoidance of the open air, the cessation from bodily exercise,
the want of attention to diet, and to the healthy performance of
the functions of the skin." In support of this view, Mr. Toynbee
has given the dissection of eighteen cases, a portion of those al-
ready enumerated at page 110; and the results obtained were
thickening of the mucous lining of the tympanic cavity, and also

* German vniters often style the auricle the ohrmutchelj from its likeness to a mascle-
shell or conch.

268 STRUMOUS MTRIMGITIS.

of the membrana tympani, with the existence of bands of adhe-
sion connecting together the various parts contained within the
former. These evidences of previous inflammation are, however,
but what might be expected in the post-mortem examination of
any of the mucous or serous cavities in aged persons, and the con-
dition of the ears in those dissections is similar to what the same
author has shown is the chief cause of deafness in persons at any
period of life.

STRUMOUS MTRINGITIS.

I have had some difficulty in determining whether to place
the following disease among the affections of the cavity of the
tympanum or the membrana tympani, for, its seat being in the
mucous layer of the latter structure, it is manifest that it must,
sooner or later, spread over the whole ca vitas tympani, and is
consequently common to both. As, however, the visible signs of
the disease are most apparent on the membrana tympani, I have
classed it along with the affections of that part.

This is a frequent affection in young persons, and, I believe, a
▼ery constant cause of deafness in after life. Its subjects are usu-
ally from five to fifteen or sixteen years of age, but it may appear
at a much later period. It chiefly attacks the light-haired, fair-
skinned, blue-eyed, and those who exhibit well-marked evidences
of a scrofulous constitution. Its first symptom is that of deafness,
generally attributed to inattention : scarcely a fortnight passes that
I do not see a boy or a girl, from ten to fifteen years of age, from
some of the public schools, who, having been deaf for two or three
months previous, had been constantly reprimanded for inattention.
If the relations are asked why they did not take advice for the
child before, the general answer is, ** We thought it was only a
cold, and would not signify."

The auditory passage is usually dry, but seldom red. The
tympanal membrane will be found of an uniform pinkish hue, but
without either thickening or opacity, at least in the early stages.
This colour, which is somewhat the tint of pink blotting-paper,
appears to be seated in the mi^cous layer, and shines through the
other laminae of the membrane, which still preserve their polish

STRUMOUS MTRIN0ITI8. 269

and transparency. There is generally mucous engorgement of
the cavity of the tympanum, with thickening and increased red-
ness of the faucial mucous membrane, — a condition which, there
can be little doubt, extends through the lining of the Eustachian
tube into the middle ear. It is, generally speaking, a painless dis-
ease, and but seldom accompanied by tinnitus in the first instance ;
occasional crackling sensations, gurglings, and loud reports, are
felt in the ear, and sometimes temporary relief is experienced
therefrom. Catarrh, stuffing in the nose and frontal sinus, and
great liability to ** cold in the head," are not unusual symptoms,
or rather attendants ; there is no pain on pressure in or about the
ear, the throat, the mouth, br the Eustachian tube. Strumous
affections of the eyes are not an unfrequent complication, and
these, particularly corneitis, which it very much resembles, and
also strumous ophthalmia, sometimes alternate with the affections
of the ear, as shall be further explained in this chapter. Enlarge-
ment of the tonsils is a very frequent accompaniment ; and glandu-
lar swellings about the neck not an uncommon appearance in such
cases. The amount of deafness varies from a hearing distance of
eight or ten inches to total inability to hear a watch applied to
any part of the head, or held between the teeth, or even to hear
what is said in a loud and distinct voice ; and, generally speaking,
the amount of redness and vascularity presented in the membrane
of the drum is in the ratio of the amount of deafness ; but the lat-
ter is very variable, and would, in many instances, appear to be
influenced by the state of the atmosphere, — being greatest in damp,
moist weather. In some cases the redness assumes a dark, damask-
rose colour, and then we may generally rest satisfied that the
entire of the middle ear is engaged. Simple mucous discharge
occurs occasionally, and purulent otorrhoea succeeds in the more
aggravated cases, as the disease advances, but it need not present
at any period of the affection. The constitution is generally be-
low the standard of health ; the patient is usually pale, languid,
and inactive, with, perhaps, slight loss of appetite, and some dry-
ness of the skin.

This form of myringitis is very liable both to relapses and re-
turns, and of this latter circumstance the patient or the friends

S70 gTBUMous mranroiTis.

Aould be always informed. When once a child has had this com-
plaint, the slightest exposure to cold may re-induce it.

The treatment in this disease should be chiefly directed to im*
prove the condition of the constitudon, and I know nothing better
for effecting this object than the use of bark in its various prepa-
rations, conjoined with iodide or bromide of potassium, and, when
the inflammation is of a more active character, the bichloride of
mercury. In the advanced stages, and where there is much con-
stitutional taint evident, with enlargement of the cervical glands,
Ac., the oleum jecoris will be found most effectual; but whichever
of these may be employed, it should be steadily persisted in for a
length of time. This is a slow and tedious disease, lasting, even in
the most favourable cases, for months, and being liable to relapse,
patients should be carefully watched, and their ears examined at
least once a week, while any trace of inflammation remains. A
dry, pure, country air, and a residence by the sea-shore in sum-
mer, will always be found beneficial ; but, as far as my experience
extends, I have always found bathing in the open sea injurious.
The warm bath occasionally, appears to be of use. As in cases of
strumous ophthalmia, so in scrofulous myringitis, a leech or two
may sometimes be required, although depletion is not generally
indicated.

As the tongue is usually white and clammy, and the dejections
of^n vitiated, small doses of chalk and mercury, combined with
rhubarb and columba, given as alteratives every second or third
night, will assist our other means. The diet should be light and
highly nutritious, while all acid fruits, pickles, and ill-boiled or
stale vegetables, even made dishes and pastry, should be avoided.
Constant open air exercise during the fine part of the day is very
necessary ; and when the weather is at all harsh, cold, or damp, a
light covering should be worn over the ears, or small bits of cot-
ton laid in the conchae ; but in the house, or in warm weather,
these precautions are unnecessary ; neither do I believe it at all
efficacious to keep the head warmer than under ordinary circum-
stances.

Counter-irritation will be found most effectual, and the vesi-
cating liniments more efficacious than the ordinary blistering^

STRUMOUS MTBINGITIS. 271

The strong tincture of iodine, acetum ly ttae, or croton oil and
acetic acid conjoined with spirit of turpentine oil of rosemary
and soap liniment, form very useful applications. This latter lini-
ment should be rubbed over the mastoid process, and lower down^
as far as the angle of the jaw, once or twice a day, until a slight
vesicular rash is produced, when its use ought to be discontinued
until the redness has disappeared, when it may be re-applied as
before. This irritation should be kept up for a couple of months
at least, varying the application as the parts become accustomed
to any particular substance. Whatever is used, great care should
be taken that it does not spread over the back of the auricle, which
is very likely to become inflamed and greatly swollen by it.

This is one of the diseases in which catheterism of the Eusta-
chian tube is sometimes necessary, but, I believe, not so often as
is generally resorted to. When the patient himself can readily
pass a stream of air into the drum, by making a forced expiration,
whilst we apply our ear, or a stethoscope, to his external ear, so
that we can distinctly perceive the full and natural inflation of the
membrane, the introduction of a catheter, and the pressure of a
stream of cold air, I believe to be not only unnecessary, but inju-
rious. In cases, however, where mucus has collected in the ca-
vitas tympani, catheterism may be resorted to occasionally, and
even warm water, or some bland fluid, might be thrown up by
means of a syringe, although I have my doubts as to the quantity
of any fluid which can be thus driven into the tympanum, in order
to wash out mucus, pus, blood, or other extraneous substances. As
I do not believe that the enlarged tonsils which often accompany
this disease — as they do other strumous aflections — are the cause
of the deafness and the inflammation manifest in the drum and
its membranes, I cannot recommend their removal, as has been
proposed, and acted on by others ; but the application of a strong
solution of nitrate of silver to the back of the throat and fauces,
and particularly towards the mouth of the Eustachian tube, by
means of a piece of lint attached to the end of an aneurism needle,
and applied as far up as possible behind the pillars of the soft pa-
late, will be attended with beneficial results ; and the use of astrin-
gent gargles should be persevered in during the continuance of

272 STRUMOUS MYRINGITIS.

the throat affection. If otorrhoea ensues, is to be treated as I have
recommended in the chapter upon that subject.

No. 12 in the Registry is a case of sub-acute strumous myrin-
gitis.

M. M., aged 16, a male. — It is quite manifest, from the way
in which he speaks, that this boy has been deaf a long time. His
utterance is indistinct ; there is a sort of whistling sound in his
speech, as if he sipped in the air, and then blew it out through his
nose ; his voice is hoarse and insonorous, and he labours under
that peculiarity denominated, though incorrectly, speaking through
the nose ; the tonsils are not enlarged ; the throat is normal, with
the exception of a slight elongation of the uvula, but which is
quite insufficient to account for the peculiarity of his speech; and
the nose, as far as we can ascertain, does not exhibit any conge-
nital peculiarity or acquired disease. This boy says he has been
deaf since childhood ; in fact, he never remembers hearing well ;
he has had occasional slight pains in both ears, but they never
amounted to any degree of intensity; never had a discharge from
either ear, but suffers from noise in the left. His amount of hear-
ing varies considerably from time to time, and is much decreased
whenever he catches cold.

Right side. — Hearing distance three inches. Auricle and mea-
tus normal ; tympanal membrane white, thickened, opaque, and
slightly collapsed, or pressed inwards from its natural curvature ;
its lower edge vascular. He cannot inflate his drum ; but the at-
tempt to do so increases the inferior vascular crescent, and causes
several large red vessels to appear upon the upper half of the mem-
brane.

Left side. — Only hears on touching. Membrana tympani ex-
hibits a uniform pinkish colour, somewhat resembling the hue of
a rose-leaf; the thickening and deposit has not yet taken place.
To introduce an instrument into the Eustachian tube, and force
fluid or gaseous bodies into the middle ear, would, I believe, in
all such cases, be of little avail until we subdue the local inflam-
mation, and correct the constitutional tendency to its return. The
treatment consisted in slight local depletion frequently repeated,
long-continued counter-irritation over the mastoid process, and the

OTITIS IH CONVBZIOV WITH OPHTBAUaA. 273

exhibitioii of such internal remedies as we know by experiencev
from the diseases of analogous organs, improve the constitutioUi
and tend to correct the tendency to disorganizing inflammation,
such as the oxymuriate of mercury and bark, the preparations of
iodine and potassium, cod-liver oil, &c.

OTITIS IN CONNEXION WITH OPHTHALMIA.

The'following cases are typical of a form of strumous inflam-
mation of the ear with which I have been long familiar. It some*
times co-exists with, sometimes alternates with, the ocular disease*
What is termed strumous ophthalmia, and also comeitis, are the
forms which the eye affection assumes. Occasionally it is that of
choroido-iritis. We often see the patient labouring under the dis-
ease of the eye in the spring and early summer, and that of the ear
in autumn and winter. Both seem to be contingent on the same
constitutional diathesis, but the aural affection being generally
painless, and the part in which it is seated being concealed from
view, it attracts little attention, or it is attributed to stupidity*
Unhappily, in these cases the mischief has been done: the thick-
ening and deposit in the membrana tympani have already taken
place ; the inflammatory action has subsided ; we now only wit-
ness its results, and treatment will avail but little. Improvement
of the constitutional health, and placing the patient in the most
advantageous circumstances, may possibly in time produce so much
absorption as will give a moderate increase of hearing. I suppose
these cases belong to that class which medical practitioners, not
examining with the speculum, and, consequently, not knowing
what is going forward, were heretofore in the habit of telling pa-
tients or their friends *' to let alone, and in time they would grow
out of it."" If we look into the statistics of deaf-dumbness for dif-
ferent countries in Europe and America — and the same remark
holds good with respect to the investigations instituted in Ireland
on the same subject — we shall find, among the causes of acquired
muteism, ''diseases of the eyes" frequently recorded. Now, as we
cannot suppose that diseases of the organs of vision could of them*
selves produce total deafness, leading to complete loss of speech,
we are forised to the conclusion, that with the ophthalmic

u

274 OTITIS m COVVBZION WITH OPHTHALMIA.

oo«exi8ted some insidious aural^affection such as I have described,
and so intense as to produce dea&ess, and, in very young persons^
oonsequent loss of speech. It generally occurs at from five to
fifteen years of age ; but, whether it is owing to metastasis of the
morbid action from the eye to the ear, or the same strumous dia«
thesis inducing the affection in the tympanum, I cannot say.

No. 26 in Registry. — H. M., a female, aged 16, with hazel eyes,
jrellowish hair, large projecting mouth, freckled skin, glandular
swellings of the neck, and other manifestations of struma; has
been deaf for several weeks. There is an opacity of the cornea
en both sides, arising firom ophthalmia, for which she was treated
at the Institution some years ago. She had also strabismus of the
left eye, for which she was successfully operated on at twelve
years of age. Left side. — Hearing distance four inches; mem*
brana tympani opaque, densely white, and collapsed, a few red
vessels course along the handle of the malleus ; tinnitus. Right
fide. — Hearing distance two inches ; membrana tympani opaque,
and of a skim-milk colour ; tinnitus. She never suffered from
pain ; never had any discharge from either ear ; throat natural ;
tonsils not enlarged. Ordered cod-liver oil, and to have the mas-
toid region painted with strong tincture of iodine daily.

No. 27 in Registry. — A. S., a female aged 12, with dark au-
burn hair, fair complexion, and hazel eyes, suffered from pain, red-
ness, and intolerance of light in both eyes some years ago ; traces
of the affection still exist in the nebulous condition of both cornese,
and she bears the marks of glandular enlargement; has been deaf
five yeai's ; disease came on with pain and slight discharge from
both ears; the discharge has ceased for some time. Right side. —
Meatus natural; membrana tympani thickened, opaque, and of a
brownish colour, presenting the appearance of crumpled parch-
ment; hearing distance scarcely half an inch. Left side. — Mem-
brana tympani devoid of polish, and of a brownish-red hue, with a
crescent-shaped vascularity at its inferior edge ; the disease on
this side is evidently of a more recent date ; hearing distance one
inch. She states that her hearing is always better in the spring
and summer, when the eyes are usually affected. Ordered oxymu-
liate of mercury, with bark and counter-irritation behind the ears.

OTITIS m coirvBxioii with ophthalmxjl 275

Master B., aged ten years and a half, consulted me during the
post month on account of deafness, so complete as to require the
use of writing in communicating with him. He is of a strumous
family, several members of which have been deaf. He had a bro-
ther who lived to four years of age, but never exhibited consoi«
ousness, seldom moved, never spoke, did not appear to heart
scarcely to see, and was to all appearance idiotic. Master B. had
convulsions at three months old, and again when three years of
age ; he, however, grew up to be a stout, healthy boy, intelligent,
and with all his faculties perfect He is well made, has blue eyes,
and rather light hair. In June, 1851, he was attacked with severe
ophthalmia, which lasted about six weeks, in the left eye. The
disease was painless, but caused intolerance of light, and was cha-
racterized by redness of the globe, lachrymation, and great indis-
tinctness of vision. He was then seized with hooping cough, and
after the interval of a month the right eye became aflfected simi-
larly to that on the left side. During the winter his eyes got well,
with the exception of an opacity on the right cornea ; and in
spring it was remarked that his hearing had become defective,
and gradually lessened up to November last, when it failed alto-
gether. He cannot hear at all, even by shouting into his left ear;
but, when his mother speaks to him, by holding her mouth to the
right auricle, he is able to distinguish what is said. His voice is
beginning to be affected ; it has lost its intonation, has become
nasal, and with that sipping character — as if drawn in through
the closed teeth — characteristic of total deafness, which I have
described at page 81. He is not conscious of the ordinary street
noises ; he does not complain of tinnitus. Within the last two
months he has become very nervous, starting up in his sleep with-
out any apparent cause, especially if he awakes and does not find
a light in his room, — although this does not seem to arise from the
usual feeling which some children have on that subject. Latterly
some unsteadiness of gait has been remarked ; and there is a more
than usually frequent desire to urinate, especially aA;er lying down.

The auricles are normal, as also the external apertures of his
ears, although the latter are dry and devoid of cerumen. The

v2

276 OTITIS IN CONVBXIOH WITH OPHTHALMIA.

membraiue tjmpanorum nearly the same on both sides ; are very
much altered from the natural character ; have lost their transpa*
rency, polish, and curvature, being now white, thickened, opaque,
and slightly collapsed. There is still some vascularity around the
tubercle and handle of the malleus, the result of previous inflam*
mation, with lymphy deposit in the membrane. All that can be
learned of the state of the cavitas tympani is, that it is unsusceptible
of inflation upon the right side, and scarcely admits any air upon
the left ; but that the inflammatory action, which has left such ma-
nifest traces in the external membrane, must have extended over
the tympanum, and possibly into the labyrinth, there can belittle
doubt. From this boy's hereditary tendency, his slight irregula-
rity of gait, the nervous startings at night — so common to partially
deaf people — and the tendency to frequent action of the bladder, it
is not unlikely that his brain and spinal marrow may be engaged,
though in what manner it is difficult to determine. The prog-
nosis is not favourable to a recovery of hearing, yet it is not alto-
gether hopeless, and the constitutional symptoms may possibly be
grown out of The treatment recommended consisted in long-
continued counter-irritation behind the ears and round the nape
of the neck, with the use of iodine in minute doses, taken in the
form of a mineral water.

In cases of this nature, the patient should be encouraged to
■peak as much as possible, and on no account allowed to employ
signs or finger- writing. He should be spoken to in a clear, distinct
tone of voice, not too loud, and the mouth removed from his ear
gradually day by day, so as, if possible, to educate the sense and
increase the hearing distance ; he should also be made to read
aloud every day. The company of persons of his own age will
be advisable, provided they are not allowed to resort to signs in
communicating with him ; and his mind should be engaged with
some pleasing, healthful occupation.

The further treatment — medical, moral, and educational — of
the partially deaf, either congenital or acquired, will be considered
in the chapter upon Deaf-dumbness.

TYPHOID INFLAMMATIONS OF MBMBBAVA TTMPAVX. 277

TYPHOID AND EXANTHEMATOUS INFLAMMATIONS OF THE MEMBRANA

TYMPANI.

In the otitis accompanying scarlaUna^ measleSt and amaUrpox^ I
believe, as I have already stated, that the disease either commences
in the mucous lining of the middle ear, or spreads into that cavity
from the mouth and fauces through the Eustachian tube. Sooner
or later, however, the membrana tympani becomes engaged, and
is ruptured either by ulceration or from the pressure of the con-
tents of the tympanum, and otorrhoea, with its long and varied
train of consequences, ensues. This form of inflammation is there*
fore considered under the head of diseases of the cavitas tympani.
Moreover, I am not at present able to state from personal know-
ledge what are the peculiarities of the inflammation which pre-
cedes the discharge in those cases ; as, although of very common
occurrence, the practitioner in aural surgery does not in general
see them till long after their first appearance, — seldom, indeed, till
the disease becomes chronic, and complicated with polypus; or
often not till long after ulceration has destroyed the membrane,
the ossicula have been discharged, and other irreparable mischief
has occurred. During the severe epidemic of influenza in 1847,
I had some opportunities of examining the membrane in the early
stage of that aflection, and I found it dark-red, thickened, and even
pulpy, like a highly injected portion of the intestinal mucous mem-
brane ; I also observed in such cases an increased and apparently
acute cerumenous secretion coating the passage.

The deafness aUmding typhus fe^yer is a well-known symptom,
although its true pathology has not been yet elucidated, because
a sufficient number of autopsies have not been made ; and we have
not well- authenticated descriptions of the appearances which the
parts susceptible of inspection during life present. In this coun-
try, where extensive opportunities for studying typhus exist, the
deafness which occurs during the progress of fever is generally re-
garded as a favourable symptom ; but I believe that that which
arises in the commencement is not so favourable. I can only
speak as to the results. In a few instances the membrana tym-
pani was perfectly natural, and the tympanic cavity free; and
the patients presenting such generally had a bad form of fever,

278 TnHOID nrFLAMXATIONS OF MBMBBANA TTXPAVI.

with very severe head symptoms. Such cases I suppose to be
analogous to the amaurosis which sometimes arises during the pro-
gress of fever, and often remains permanently, being a cerebral*
and not an ocular, disease. But in the great majority of in-
stances the membrana tympani presented evidences of dideaset
being generally thickened, opaque, and collapsed ; I am, there-
fore, led to believe that, in very many cases, the dea&ess oc-
curring during the course of a fever is the result of inflam-
matory action in the ear itself, and not in the brain. In this
opinion I am borne out by the dissections of M. Passavant, who
says, that in *' patients cut off by typhus fever,** — and he has always
found certain pathological lesions corresponding to the symptoms
observed during life, — *^ the petrous portion of the temporal bone is
congested, and the congestion extends to the internal parts, ex*
cept those of most solidity. The transparency of the tympanum
has disappeared ; the membrane is thickened, red, and its epithe-
lium peels off with great readiness. This injection of the mem-
brana tympani extends some way along the external auditory ca-
nal, and in some cases small spots of ecchymosis are found between
the injected vessels. The cavity of the tympanum contains a
thick, viscid mucus, which is also found in the Eustachian tube,
and in the cells of the mastoid process. The mucous lining of the
middle ear is congested likewise, of a rose or bluish-red colour.
The labyrinth does not present any constant alteration, though
some points of injection are occasionally observed."* I have ob-
served that suppurative otitis is not common in typhus, while it is
the chief characteristic in the disease occurring during the pro-
gress of scarlatina or measles, where the membrana tjrmpani is
almost invariably perforated, and a bad form of otorrhoea results.
I think it, therefore, more likely that, when local disease is set
up, — and from the organic changes subsequently observed, there
ican be no doubt of the fact, — the inflammation is seated in the
fibrous structures, and not the mucous lining of the ear. Typhus
occurring in children is a cause of acquired muteism, for which
see the following chapter, and also that on Deaf-dumbness.

* Zeitflchrift fur Rationalle Medizin, quoted in The Medical Times for April ISth,
IS^I. For fiurtbcr inCmmuitUMi aee the Mcttoof on Otitis and Acquired Muteiim.

CHRONIC MTBINaiTIS. 279

CHRONIC MYRINGITIS.

Chronic inflammation of the membrana tympani is a very fre-
quent cause of deafness, as may be seen by referring to the Table
at page 102 : no less than 396 cases out of 2385, or one in every
six, having presented at the hospital in the period specified. To
these might be added the 219 cases of thickening and opacity of
the membrane, but that> in a practical and a therapeutic point
of view, there is a manifest difference : the former being fire<-
quently within the pale of art, whereas the latter, if of long 8tand->
ing, is generally irremedial, and it is more frequently accompa-
nied with collapse. In chronic myringitis there is generally some
evidences of inflammatory action going forward. Whatever may
be the original cause of the disease, it is one that comes under out
notice daily ; and, although many cases present as such in the be**
ginning of the deafness, the appearances of chronic inflammation
of the drum are to be foimd as the sequelse of nearly all the other
forms of inflammation, in the same way that we find chronic oph-
thalmia so frequently a sequence of the various acute forms of
inflammation of the eye. In external otorrhoea the membrana
tympani is generally in this condition ; but there are two other
special forms of chronic inflammation which may be constantly
observed, — ^the first, a perfectly painless deafness ; the other at-
tended by paroxysms of pain, ooming on at intervals, between
which the patient is perfectly free from all uneasiness. The lat*
ter is much more common among females from twenty to forty^
and is at times accompanied by irregularities of the uterine func-
tions. The appearance of the membrana tympani is too peculiaif
to be mistaken : it presents a general thickening and opacity, par^
ticularly of its lower portion ; besides which there is almost invi^
riably a number of spots, about the size of pin-heads, of greater
density than the rest, and of a pearly lustre, studded over the sui^
face of the membrane. In many cases it presents the appearance
of crumpled parchment During the quiescent periods, we only
remark a few straggling vessels, carrying red blood, spread over
the surface of the membrane, and, for the most part, coursing fi*om
above downwards, parallel with the handle of the hammer. Upon

280 CHBono mraiRQiTis.

any provocation, however, such as cold, or other exciting causes,
the membrane will, in a few hours, and often without any increase
of pain, become of an uniform dark-red colour, precisely like />an-
nu8 of the cornea, a disease of which it is the manifest analogue.
The greater the amount of thickening and opacity, the less will
be the quantity of vascularity and redness which the membrane is
capable of assuming, as we perceive in cases of dense opacity of
the cornea, owing, no doubt, to the greater quantity of deposit
obstructing the flow of red blood, by diminishing, and, perhaps,
also obliterating, the caliber of the vessels. In such cases the mem-
brane is often insensible.

I have frequently seen a thin, skim-milk-coloured scale on the
membrana tympani, like that which mineral lotions, lead, or alum
occasionally leave on the cornea, with a number of fine radiating
clear lines interspersed through it, as if the deposit had cracked
in these places.

Cases of this kind are often of many years' standing, and many
have, I am convinced, been treated as instances of *< nervous deaf-
ness.** The following is no imaginary case, but one of constant
occurrence.

A lady, aged between 30 and 40, applies for advice. She is
very deaf, speaks in a loud, inharmonious voice, and has suffered
from noise in her ears, of all descriptions, for several years. She
usually prefaces the detail of her symptoms (which is generally
very long and verbose) by stating that she does not think much
can be done for her, for that she is labouring under nervous deaf-
fies9, and is, therefore, incurable. She has a great objection either
to be questioned or to have her ears examined until she has made
a full statement of her case ; and as she has had a great variety of
opinions, and has used all manner of remedies, she is tediously accu-
rate in her account. She also carries in her hand a formidable
Ust of questions. She states that she has been deaf from a very
early period ; that at first her deafness was attributed to inatten^
tion, and endeavoured to be remedied by the means thought most
advisable by her guardians and governesses, and the family doctor ;
that, her disease increasing, she was brought to an eminent prac<
titioner, who, after a few casual inquiries, but without examining

CHBONIO MTBINQITI8. 281

her ears, told her Mends not to mind it, for that she would cer-
tainly '* grow out of it** as she grew up, and that probably all her
deafness would disappear about the period of puberty ; but that
she might rub eau de Cologne on the jaw occasionally ! With the
exception of sea-bathing, and means calculated to improve the
state of her general health, no other remedies were tried, and no
other advice sought for two or three years; when, not finding the
hearing improved, but gradually becoming worse, and the tinnitus
increasing as she grew up, a special aurist was consulted, who
stated the disease to be entirely local, and curable by local reme-
dies alone. During the next few years, various means were had
recourse to: catheterism of the Eustachian tube was employed for
several months, the tympanum constantly washed out, and various
liquids and gases injected into it, but without effect. Counter-
irritation was next employed, with issues in the arm and setons in
the neck, and a long and fair trial given to their powers. It was
next proposed to remove the tonsils, or, at least, portions of them.
Still the disease progressed. Drops, oils, — eel-oil in particular,—-
and divers liniments were tried in vain.

Broken down in health, wearied by the variety of opinions and
the multiplicity of applications, another eminent physician was
then consulted, who, having heard the history of the case, advised
the cessation of all local remedies, and recommended tonics and
antispasmodics, together with shower-baths, change of air, and
sea-bathing : stating at the same time that the disease was entirely
constitutional, and of a nervous character. And certainly by this
time, from hope deferred, — for many specious promises of cure had
been made, — from the increase of the tinnitus, and from the effects
of the long and severe treatment, the patient had become remark-
ably nervous and irritable, brooding over her malady, and ren-
dered unhappy and discontented by being imable to take part in
any general conversation.

Some years now passed without her doing anything ; she had
not become much worse, but she certainly had not improved. Ow-
ing to some new theory being started, at the solicitation of friends
who had been relieved of some curable form of deafness, or from
the celebrity of some particular practitioner, she was again induced

282 CHBONIC MTBIKQITI8.

to seek relief; and having arrived at the metropolis, she took the
round of the doctors and aurists. Some proposed perforation of
the drum, others recommended travel; the honest prescribed no-
thing ; the quack proffered his panacea, or offered to sell his pe*
culiar acoustic instrument, and backed the recommendation of its
merits by the sign-manual of persons of rank and position.* The
homoeopathistSy hydropathists, and mesmerists, were each con-
sulted, and the merits of their systems tested; heavy wet without,
and infinitesimal nothings within, got every fair play ; and a lock of
the lady's hair was sent to Paris, to a celebrated practitioner in elec-
tro-biology ; the Spas of England and the Badens of Germany were
visited, and their efficacies tried ; electricity, galvanism, and electro-
magnetism, were also had recourse to, but ail in vain. The opinions
of those whom she had consulted were as various as the remedies
they employed : but the greater number believed it to be a constitu-
tional or nervous affection. Latterly she had been content to look
out for *' cures*" among the newspaper advertisements, and of these
she possessed a large number in her portfolio.

Of several such cases, scarcely differing in a shade, I possess
the notes. In these the following may be gleaned upon a care-
ful examination. The membrana tympani is thickened, opaque,
slightly vascular, and sometimes much collapsed or drawn in-
ward towards the inner wall of the tympanum, so that the han->
die of the hammer forms a manifest projection: it has also lost
its polish and become of a dull pearl-colour. On questioning the
patient closely, it is acknowledged that attacks of ear-ache were
suffered several years previously, particularly in winter, and that
such attacks were often preceded or accompanied by stuffing in
the nose, and symptoms of catarrh, and were generally induced
by cold, to avoid which the head was usually kept warmly muf-
fled during such seasons.

In such a case our art at present does not offer much hope.
The whole train of symptoms are evidently the result of slow
chronic inflammation, affecting, in all probability, the lining of

* In a window in the Strand, not far from Somerset House, London, may be seen,
framed and glazed, a certificate from one of the Chief Justices of England, lauding and
noommending, ** to all whom it may conoern,** a particnlar form of ear tnimpet !

CHBOmC MTBINGITI6. S83

the cavity, as well as the membrane of the drum, like repeated
attacks of choroido^ritis in the eye. The only means which can
with safety be recommended at this period is the application of a
solution of lunar caustic, applied with a camePs hair brush, every
third or fourth day, upon the surface of the opaque membrane,
while it is fully exposed to view, and should there be much vas-
cularity present, the application of a few leeches as far in as pos*
sible round the meatus, at least twice a week. In a few cases the
arnica will assist to remove the tinnitus ; but it is not so ef&ca*
cious in this as in more recent forms of the affection.

In the cases of periodic pain, with a higher degree and more
generally diffused vascularity, the application of leeches, applied
every second or third day, will be found most efficacious ; at the
same time that the patient should be brought under the gentle in*
fluence of mercury, and kept so for at least a month. Under such
treatment, if the case is not of too long standing, the hearing will
often be improved, and the symptoms of pain and tinnitus re-
moved. The membrane will clear somewhat, but in most cases
the spots of opacity remain indelible. In applying the solution of
nitrate of silver with a fine brush, or a bit of cotton- wool on the end
of a probe, some caution and dexterity are required, as the mem-
brane may present a small perforation the next day if it has been
rubbed too hard ; and although I have always seen such perfora-
tions heal readily, it is an accident which should be avoided.
By this application dark scales peel off the surface of the mem-
brane, and leave it thinner and more transparent than before ; but
the moment it becomes inflamed we must desist. I knew two in-
stances in which the tinnitus was always relieved for several hours
or even a day after simply rubbing the surface of the membrana
tympani with a bit of moist cotton.

There is a form of deafness with which I have been long fa-
miliar, which may be the result of some form of inflammation. In
such cases, upon bringing the external membrane of the drum into
view, we do not observe any general thickening or opacity of it,
or any apparent alteration of its texture, but a crescent-shaped
opacity, about a line broad and three lines long, with a tolera-

284 CHBOKIC MTRIKGITI8.

bly defined edge, and rather rough upon its surface, occupies
the lower and usually the back portion of ^he membrane. It
is generally more insensible than the rest of the membrane, and
differs from the ordinary opacity, in the surrounding structure
being apparently free from disease, in its almost invariable seat,
its well-defined edge, and in its having a portion of unaffected
membrane between it and the bony attachment of the membrana
tympani. By a very slow and gradual process this disease spreads
over the greater portion of the membrane, and produces porma*
nent deafness. I am not aware of any remedy for it.

In some instances I have observed a manifest granular state of
the membrane, not unlike the surface of a half-ripe raspberry, the
intervening portions between the reddish elevations being thick-
ened and opaque ; it is unattended by discharge. In these cases I
have procured an uniform thinning and clearing of the membrane,
by the occasional application of a fine point of nitrate of silver;
but this requires very great care, and should be persevered in for
a great length of time, at least two months ; it should, if possible, be
applied so lightly as not to induce a discharge. Many of those
cases are the result of long-continued otorrhoea, but which, hay*
ing healed, has left the membrane in this condition.

Many females have become deafimmediately after parturition.
In such cases I have generally observed a speckled opacity of the
membrane.

No. 9 in the Registry is a case of thickening and opacity of
the membrana tympani.

A. H., a female, aged 30: complains of deafness, tinnitus an-
num, and constant pain in her right ear, and partially in the left*
Greneral health impaired, she says, on account of her aural affection ;
the almost incessant hammering noise, and the pain — aggravated
whenever she gets cold — rendering her very miserable and ner-
vous. The membrana tympani upon the right side is of a pearl co-
lour, and evidently thickened by some interstitial deposit ; it has lost
its polish, but retains its natural position, and the patient can press
it outward by inflating the drum. Posteriorly, there is a well-de-
fined streak of dense white opacity proceeding downwards and

MORBID DEPOSITS IN THE MEMBBANA TTMPAKI. 285

outwards from the point of the malleus. Hearing distance three
inches. Left side nearly natural ; hearing distance twelve inches.
Scarelj ever feels any pain unless when much exposed to cold.

MORBID DEPOSITS IN THE MEHBBANA TYMPANI.

Thickening and opacity of the membrana tyrapani, with or
without flattening, collapse, or drawing inwards towards the cavity
of the tympanum, is the most frequent apparent result of each and
all of the foregoing varieties of inflammation in that structure. If
we examine into the sequelse of ophthalmic inflammation, we find
that opacity either of the cornea or lens is, in a great majority of
those instances in which the organ has not been totally destroyed,
the chief cause of loss of vision. Lymph efiused upon either side
of the membrana tympani or between its laminae is the manifest
consequence of most inflammations, in addition to which the ex-
temal cuticular layer may be thickened from pressure, as already
explained at page 188, or by extension of cutaneous diseases, as
shown at page 198 ; and within, the increased vascularity and
hypertrophy of the mucous lining of the tympanic cavity over the
posterior surface of the membrana tympani naturally gives rise to
permanent thickening of this structure. An examination of the
Registry of 200 cases in the previous part of this work, and the
analysis of that Registry, at page 136, will explain the various
conditions of the membrane to which I have so frequently alluded.
It is possible that in those cases where we observe clear, pocket-
like projections in the surrounding opaque membrane, that either
from rupture, ulcer, or an outspreading of the fibres of the true cen-
tral laminae, that there is a partial deficiency of the membrane at
these spots ; but we require minute pathological investigation to de-
termine which particular structure is deficient. It is, however, very
probable that these projections are formed by the mucous mem-
brane bulging through, and the dermoid layer being pressed out-
wards, like what takes place in a sacculated bladder, occasionally
in the iris, and often in the cornea.

Atheromatous or calcareous deposits form between the laminae
of the membrana tympani, and generally occur in middle-aged fe-
males. The deposit is usually seated in the anterior vibrating

286 MOEBID DEPOSITS UT THE MBMBBAMA TTMPANI.

portion, is of a yellowish colour, and has a sharp, well-defined
but irregular edge, totally different from that of a lymphy exuda-
tion, which generally shades off into the surrounding membrane.
If scratched with a cataract needle, it will be found giitty, but what
its exact composition is I cannot tell. I believe I was the first to
notice this peculiar appearance, ten years ago, in my essay upon
Otorrhosa, where I then stated, at page 38, '' I have in three in-
stances seen earthy deposits between the layers of the membrane
like those which are found in the heart and arteries and cornea;
ihey were regular in shape, occupied about one half of the tense
portion of the membrane, and afforded a gritty feel when touched
with a sharp instrument. In each case, severe deafness existed in
that ear. In one of these cases, that of Lady B., I pointed out
this peculiar morbid deposit to Sir H. Marsh, about eight months
ago"" (1843). Four such cases are noticed in the Registry (see
page 137), and I have also seen several others in private prac-
tice. Sensibility remains in these. I believe the disease to be
incurable.

Thickening and opacity of the membrane is as difficult of cure
as the same appearance in the cornea. Much must depend upon
the age of the patient, who may outgrow it ; upon the state of the
general health, from the removal of the opacity, being a process of
absorption ; and also upon the length of time which has elapsed
since the original inflammation existed. The diagnosis should
always be guarded : if redness and vascularity still linger about
the membrana tympani and external meatus, we may entertain a
hope of improving the patient's condition by the means pointed
out for treating chronic inflammation in the foregoing section, and
the employment of such constitutional and dietetic measures as
serve to correct or alter the exciting cause. But if the patient has
passed thirty years of age; if all vascularity has been removed; if
the meatus is dry, scaly, and totally devoid of cerumen, and that
the membrana tympani presents upon its external surface a uni-
form sheet of pearlaceous whiteness, with perhaps one or two su-
perficial red vessels coursing along the malleus, treatment does
not hold out a hopeful chance of success. We see enough of ma-
nifest disease to account for the deafness, but we cannot tell in

MOBBID DBP08IT8 IN THB MBMBBAVA TTMPANI. 287

what condition the membrane lining the tympanic cavity may be ;
what amount of opacity and thickening may have taken place in
the membrane of the fenestra rotunda ; whether anchylosis of the
stapes to the fenestra ovalis exists ; or whether bands of adhesion
have formed between the membrana tympani or the ossicula and
neighbouring parts. Even supposing that none of these patholo-
gical changes have happened, and that the disease simply consists
in an opacity of the membrana tympani, and that the patient is in
good health, and absorption going forward, a year and more must
occur before we can expect the membrane to clear, either in whole
or in part, and few persons will be found with sufEcient confidence
and patience to carry out the prescribed treatment; yet I have
sometimes been astonished at the favourable turn which some of
the most unpromising cases have taken, in the instance of per-
sons who, like the woman in Scripture, prevailed through their im-
portunity, even after I had given a most unfavourable prognosis.
The treatment, like that of chronic inflammation, consists in
painting over the surface of the membrane with a solution of
nitrite of silver, of from ten to twenty grains to the ounce, about
twice a week. A cameFs hair pencil is not so good a means of ap*
plying it as a bit of cotton- wool twisted round the end of a probe,
as it should not merely be applied, but rubbed over the membrane,
which in such cases is almost insensible, and after a few applica-
tions will become blackened in patches, showing the usual efiect
of lunar caustic on dermoid structures. We must then desist until
these dark scales peel off, and when they do, we should continue
the application. Should, however, the membrane become vascu-
lar or inflamed during the process, the use of the caustic must be
omitted until the parts become quiescent. The patient, if intelli-
gent and careful, may be taught to apply the caustic, but the parts
should be inspected at least once a fortnight. Under this plan of
treatment I have succeeded in thinning the membrane and restor-
ing hearing in most unpromising cases, whereas in others I have
utterly failed. I have tried iodine and other substances, but have
not succeeded with any so well as the nitrate of silver. Counter-
irritation should at the same time be kept up over the mastoid
process.

288 00XXAP8S OF THB MBMBRAVA TTHPAn.

COLLAPSE OF THB MBMBBANA TTMPANI.

Collapse, or falling inwards, of the membrana tjmpani, towaid
the middle ear, is a very constant appearance observed in making
aural examinations, as already remarked in the Analyns of the
Registry at page 138, where this peculiar affection is described. I
have remarked two forms of this peculiarity. In one the mem-
brane is thickened, opaque, and exhibits all the evidenoes of
previous inflammation ; in the other, its texture is unaltered, it
has merely become pressed inward towards the cavitas tympani,
leaving the tubercle and handle of the malleus projecting out-
wards in strong relief. The former is always accompanied by
severe deafness ; with the latter form need only be associated tin-
nitus, although deafness often accompanies it. Cleland was aware
of this peculiar condition of the membrana tympani more than
one hundred years ago, as I have shown at page 14 of this work,
to which passage I would here refer the reader. Several old
authors have written upon a disease which they call relaxation of
the membrana tympani, — Willis, Joseph Frank, and others, sup-
posing that, when it was relaxed, it fell inwards, while Beck con-
ceived that it pressed out towards the external auditory passage,
which, I believe, only occurs from accumulations in the tympanum.
Were we to rely upon authorities and not upon observations and
facts, we might still look upon the question as undecided ; but that
the membrane is, from some cause or other, frequently rendered
more concave than natural and pressed inwards toward the tympa*
num, does not admit of a doubt. Kramer, in his criticism of Willis,
adduces as insupportable the assertion of some forms of deafness
being improved by loud noises occurring in the vicinity, — as, for
instance, while a drum was beaten in a room, and *' that an indi-
vidual, whose hearing was defective, heard everything during the
ringing of a peal of belb."* Yet, it is a well-established fact, that
certain deaf individuals will be able to hear the human voice in
its ordinary tones, and to enter into conversation while travelling
in a carriage, walking in a street through which vehicles are pass-
ing, or under any circumstance in which the air is agitated by
noises much louder than those in which the conversation they are

G0LLAP8B OF THB MBMBBANA TTMPAHI. 289

listening to are addressed. Thus, I knew an instance of a miller
who could hear perfectly well ordinary conversation while stand-
ing within the working mill, but so soon as the mill ceased, or
that he removed into another locality, he could only hear when
spoken to in a much louder tone of voice. This peculiar symp-
tom, a satisfactory explanation for which has not yet been given,
has generally been enumerated as one of the characteristics of true
nervoua deafness. Thus, Kramer himself, when describing his
*' erethitic form of nervous deafness,** says, notwithstanding his pre-
vious criticism of Willis, that, '* if the patient sit in a cart which
is rattling quickly over a stone pavement, or presses his forehead
against the frame of a window whilst a waggon is rattling past,
so that the whole house is shaken by it ; or if a peal of bells be
ringing near the patient, or a drum be beaten, the auditory nerve
becomes so excUed by those deep-toned uniform noises that, whilst
they continue, the patient often hears the human voice better than
a sound person whose ear is stunned by the noise.** The facts are
certainly as thus stated, but the inference does not follow. We
have no authority for believing, neither are there any known phy-
siological circumstances to warrant, the assertion, that the audi-
tory nerve becomes thus excited ; or, if excited by grave tones,
that it is at that moment more capable of appreciating sharp or
acute tones. This peculiar phenomenon has always appeared to me
more explicable by a consideration of the state of tne membrana
tympani, and it is remarkable that it does not occur in cases where
that structure has been in whole or in part removed. Cleland, as I
have already remarked, believed that the altered position of the
membrana tympani was caused by '^ a violent clap of thunder,
noise of cannon, or the like.** I do not remember having met with
an instance arising from the former cause ; but it is not improba-
ble, that some of the cases of deafness which commonly occur
among the artillery may be owing to a collapse of the membrana
tympani.

The cause of collapse some writers have endeavoured to ex-
plain, by supposing that the tensor tympani muscle had snapped,
or that the ossicula and mechanical apparatus of the middle ear
had become deranged ; but, from the fact that, in all cases of col-

X

290 OOLLAPSB OF TUB MSMBBANA TTMPAMI.

lapee, the handle of the malleus is not drawn inwards along
the membrane on each side of it, I am not inclined to entertain
that opinion. I believe the collapse may, in most instances, be attri-
butable to one or other of two causes, — partial or complete closure
of the Eustachian tube, by which means the pressure of the exter-
nal atmosphere must of necessity drive the membrane inwarda;
and inflammation of the cavity of the tympanum, when adhesive
bands have formed between the internal surface of the membrane
and the neighbouring parts, which, as shown by the dissections of
Mr. Toynbee at page 111, appeared in as many as 179 itny^||^«>f^
out of 915 examinations.

This IS a cause of deafness most difficult to treat ; but, unless
some other disease coexist with it, we may generally assure the
patient that the deafness will not increase. When once the mem-
brane has been pressed for any length of time inwards, it is very
difficult to restore its position permanently. Many persons inflate
the drum, by holding the nose and making a forced expiration
whenever they wish to hear what is said. In others we can tem-
porarily restore the natural position by Eustachian catheterism ;
but in both the membrane returns to its former condition in a sh<^
time. I have tried the effect of exhausting the air in the ezter>
nal meatus by means of a syringe accurately adjusted to the outer
aperture ; but I have not effected any good thereby. On the con-
trary, I think the congestion produced by the exhaustion is rather
detrimental to the organ. I have frequently afforded temporary
relief by dropping with a glass tube a little nitrous ether into the
meatus, and immediately stopping the external aperture either
with the finger or by pressing the tragus over it. Some slight
pain is instantaneously felt, followed by a boiling sensation, then a
glow of heat, and a feeling, to use the patient^s expression, as '^if
the drum of the ear was sucked out" It is difficult to understand
how this remedy acts, and assists to restore the membrane to its
normal position.

The following case. No. 15 in the Registry, showing thicken-
ing and collapse of the membrana tympani on both sides, is highly
characteristic of the affections described in the three foregoing
sections.

COLLAPBB OF THB MEMBBANA TTMPANI. 291

M. K., a married female, aged 46, has suffered from deafness
accompanied by noise in her ears, occasional headachs, and gene-
ral nervousness, for the last ten years. Cannot hear the ticking of
the watch, though pressed against the ears, on either side. Her
disease crept on gradually ; is made worse on catching cold. She
has not experienced pain in the ears, and has no hereditary ten-
dency to deafness. The tongue is clean ; throat normal ; pulse
natural ; digestive functions healthy ; the voice, however, is harsh,
husky, and inharmonious, showing that she has been deaf a long
time.

What have we learned from the subjective symptoms just de-
tailed of the actual cause, proximate or remote, of the deafness in
this case ? Absolutely nothing. Its early history is obscure, and
the symptoms described are common to many affections of the ear.
By her ordinary medical attendant, if she was in a rank of life to
have one, her disease would be set down as a case of '* nervous
deafness,** because it has been of such long standing, has resisted
or is now unamenable to treatment, and because this poor woman
has, from her loss of hearing, and the noise in her ears, become
*' so nervous.** Her treatment, she says, has consisted in being
syringed by a doctor, who, finding the remedy ineffectual, then
recommended her ** not to be quacking, lest she might lose the
little hearing she had ;" in pouring " drops,** which she saw adver-
tised in a newspaper, into her ears every night for three weeks ;
in using '* brandy and salt,** which a charitable lady recommended
to her as an infallible remedy when that nostrum was in vogue ;
in inserting a '' piece of rusty bacon** into her ears at the sugges-
tion of an *' old woman ;** in applying glycerine, because she
heard it could do no barm ; and, lastly, in having tobacco-smoke
blown into her ears by a '* travelling aurist,** which caused her to
faint, and rendered her weak and debilitated for several days after.
Since then, having lost confidence in treatment, she has not ven-
tured to seek relief.

Let us now see what is the state of the affected organ. The
appearances are nearly the same on both sides ; the meatus is ra-
ther smaller than natural, dry, vascular, and totally devoid of ce-
rumen ; the membrana tympani is thickened, white, and greatly

x2

f92 QOLLAJfm OF THB MBMBRAHA TTMPAMI.

ooUapsedy so that the tubercle and handle of the malleus, to which
it is attached, stand out much more prominently than they ought.
Owing to the irritation produced by the insertion of the speculum,
several red vessels have begun to appear upon the tympanal mem-
brane, particularly along the site of the malleus. These are not
the appearances of present inflammation, but are the result of the
enlargement of the vessels, caused by long-continued previous in-
flammatory action ; and they are now rendered apparent by the
slightest irritation. We constantly observe the same phenomenon
in an eye which has recently sufiered from internal ophthalmia.
The conjunctiva and sclerotica may be, to all appearance, natural ;
but, upon rubbing the globe with the lid, or subjecting it to any
other exciting process, we reproduce the well-marked pinkish zone
round the cornea which characterizes inflammations of the inter-
nal tunics. This patient has not suffered pain in the ears, and the
absence of this symptom is often brought up by medical men in
proof of the non-inflammatory nature of the disease ; but we all
know now, that sub-acute inflammation may exist in other organs
of the body, — in the lungs, the eye, the liver, and the mucous and
serous membranes, — without the patient being sensible of pain.
She cannot fully inflate the drum, but she can raise up the tympa«
nal membrane a little — a proof that the Eustachian tube is free —
and also render it more vascular. The inflammatory process has,
in all likelihood, not been confined to the external membrane of
the tympanum, but has spread over the mucous lining of that ca-
vity ; and it is more than probable that bands of adhesion exist in
the middle ear, similar to those which dissection occasionally shows
us between the pleura pulmonalis and pleura costalis, between the
various reflections of the peritoneum, or between the back or pu-
pillary edge of the iris and the anterior capsule of the lens.

As the amount of apparent disease, and the morbid changes
which are manifest in this case, are insufficient to account for the
great loss of hearing, we must attribute the defect to an extension
of the inflammation from the middle into the external ear, affect-
ing the vestibule and labyrinth, and possibly thickening or ren-
dering invibratile the membrane of the fenestra rotunda. Ana-
logy with the pathology of the eye here again assists us. In many

PSBPOBATION OF THE MBMBBANA TTMPAHI. 298

instances of internal ophthalmia do we not observe similar pheno*
mena, where the amount of mischief done to the sensitive appa«
ratus is not commensurate with the evidence of disease in the
external mechanism, and the more delicate the organization, the
less is the morbid product apparent ? This woman's chief com-
plaint is of the noise in her ears, which is so distressing that it dis-
turbs her sleep, affects her mind, and prevents her following, with
any degree of energy or interest, the ordinary occupations of life.
Treatment holds out but little hope of amendment in such a
case as this, which is one of very common occurrence indeed, in
this country. The strong solution of nitrate of silver applied upon
the thickened membrane may produce some alleviation, particu-
larly of the tinnitus ; but, from the amount of collapse, it did not
present a sufficient warrant to attempt relief by perforation. It is
manifest that, when the membrana tympani is thus collapsed and
bound down, it ceases to vibrate on the impingement of sound.

▲BTIFICIAL PEBFOBATION OF THE MEICBBANA TTMPANI.

This seems the proper place to consider the propriety of per-
forating the membrana tympani, the cases to which it is applica-
ble, and the best mode of performing it. Closure of the Eusta-
chian tube, accumulation of extraneous matter within the tympa-
num, and the thickened condition of the membrana tympani pre-
viously described, are the circumstances which writers seem to
think demand it. I do not believe it to be either required or
applicable in the first class of cases ; but that subject will be con-
sidered more at length in the chapter upon Diseases of the Eus-
tachian tube. When we are convinced that the cavity of the
tympanum is filled with uncoagulated blood, and that it cannot
find exit through the Eustachian tube, an aperture may be made
in the membrane to give it vent ; but such an aperture, being in-
tended to close after it has performed its office, is widely different
from perforation made by cutting out a portion of that structure
for the purpose of assisting hearing. To relate the whole history
of the operation for perforation, the cures said to have been
achieved by it, the various ingenious instruments invented for
performing it, and the number of essays written by distinguished

294 PBRFoaATioH or thb membbaha ttmpavi.

men upon the subject, would occupy more space than it is worth
in a practical work of this description — more particularly as the
operation has fallen into disuse of late, Eustachian catheterism
having in part superseded it, and several of the so-called cures not
having stood the test of time and close investigation, so that no
well-authenticated recoveries by the operation have been related
for several years past.

To Sir Astley Cooper has been awarded the merit of first In-
troducing the operation : he performed it with a small troehar,
but the aperture made therewith was soon found to close. There
has not been, perhaps, in the whole history of medicine during the
present century a discovery to which so much praise was at the
time awarded, that subsequent investigation and experience have,
to say the least of it, so much disparaged. In the first place, the
celebrated author was not, as I have shown at page 15, the origi-
nal inventor of the operation ; although I feel convinced he was
unacquainted with Degravers* cases, but the fault lay vrith those
who, perhaps, too rapidly, and without sufficient examination,
awarded honours well due to the man, but undeserving the sub-
ject. Itard tried the operation in a great number of instances,
but without any determined beneficial result. Kramer, whose
work contains a very just review of the operation and the authors
who have supported it, states, *' that the thickening of this mem-
brane, unaccompanied by any other disease of the ear, invariably
affords the only true indication for its perforation." Himly in-
vented an instrument which obviated the closure made by the
simple puncture of the trochar, or any other piercing instrument,
and this has been further modified by Fabrizzi and others. The
very ingenious instrument of the latter consists in a fine, round
stem, four inches long, fashioned at the end into a small corkscrew
point, and enclosed within a canula working next the handle on
a nut, and furnished at the point with a sharp steel cutting edge.
When the punch or canula is screwed home, the twisted end of
the stillette projects about the eighth of an inch beyond its extre-
mity. With the end of the handle resting in the centre of the
palm, and grasped by the middle ring and little fingers, the instm-
ment is passed down to the membrana tympani, and then its spirml

PBSFOBATION OF THB MEMBBAKA TTMPANI. 295

point ia inserted into either the anterior vibrating portion or the
posterior clear space, and given one or two turns, so as to fix it
into the membrane, which, being thus held fast, the bur or nut on
the end of the canula is twisted between the thumb and index
finger outwards, or from the operator, until by this circular mo*
tion the cutting end of the punch, revolving against the portion
of the membrane held by the end of the stillette, cuts it out and
removes it entire, leaving a round aperture the size of itself. This
operation can only be safely performed with the aid of the specu-
lum, and by having a stream of clear sunlight transmitted to the
membrane. The head must be held against some resisting sub*
stance, and the patient should, if the Eustachian tube be free, be
directed to inflate the tympanum at the moment. Still, the great-
est delicacy of manipulation, and a fine, educated touch, are re-
quisite. The objection to this and any similar instrument is that,
from its size and the position of the handle, the view of the parts
under operation is obscured. To remedy this defect Mr. Tearsley
had an instrument made with a bend near the handle, — ^upon the
principle of the curve which, some years ago, I recommended in
the formation of all instruments employed upon the membrana
tympani, and described at page 57.

With respect to the best situation for perforating, we find in
books cautions about avoiding the chorda tympani nerve, which
are quite unnecessary; for, in its arch across the tympanum, it is
always far above the middle of the space either in front of or be-
hind the extremity of the malleus.

In cases of permanent thickening and opacity of the membrana
tympani, which have resisted all efforts at absorption and thin-
ning, are we j ustified in performing perforation ? I believe in very
few cases indeed will it be found efficacious, because the opacity
which we do see is but a portion of the general thickening and
disorganization of the investing membrane of the middle ear, per-
haps that of the labyrinth also, which we do not see. It may,
however, be tried without injury in some cases, but it requires
very great caution and dexterity indeed in its performance ; and, as
irreparable mischief has at times proceeded from its being done in
a rough or clumsy manner, I beg to offer a few observations on the

i

296 FBBK>BATIOM OV THB MBMBRAVA TTMPASI.

safest method of performing it. I wholly discard all instruments
in the shape of punches, trocars^ and complicated apparatus for
the removal of a portion of the membrane ; because they all oc-
cupy so much space within the speculum that it is not possible to
see accurately the point of the membrane which they are pressing
upon, nor how much of it they are cutting ; and, by our not see-
ing accurately the surface on which we are working, it is scarcely
possible to avoid injuring the malleus, or wounding the inner wall
of the tympanum ; and, moreover, those with corkscrew points,
which fix the membrane while the revolving punch cuts out the
piece, are not only exceedingly painful, but dangerous, inasmuch
as the slightest motion of the head during the operation might pfx>-
duce a degree of violence which would be destructive to this deli-
cate structure.

Having brought the membrane fairly within view, under
bright, direct sun-light, I introduce this small, sickle-shaped knife»

— with a double- cutting edge, and here figured of the natural
size in the blade, but with the shaft and handle about two inches
longer; and having made the patient inflate the tympanum, so as
to render the membrane tense, and pressed outwards, I gently in-
troduce the point of the knife into its inferior, thin, vibrating
portion, and, drawing it downwards and forwards, make a simple
incision of the membrane, about a line and a half in length. Oc-
casionally I make a crucial incision. So simple is this, and so
little pain does it give, that the patient is often unconscious of its
performance until made aware of its completion by the air rushing
out through the aperture. In about a minute a slight oozing of
blood takes place from the edges of the aperture, like that which
follows a wound of the sclerotic with an ordinary broad cataract
needle ; if left in this condition it would soon heal up ; therefore,
a very fine probe, fixed in a handle, and slightly pointed with
nitrate of silver by being immersed in the caustic when heated to
fluidity, should be immediately passed down into the perforation,
the edges of which are thereby cauterized and prevented adhe-
ring; and this latter process should be repeated from time to time.

PSBFOBATION OF THE MBMBRAHA TTMPAMI. 297

as often as the wound shows an inclination to heal, and until we
establish a sufficiently large elliptical opening.

In 1846» Dr. Butcher, of this city, read a paper before the
Surgical Society, on the subject of Perforation of the Membrana
Tympani, with a view of showing the ill consequences resulting
from the performance of that operation : and related the cases of
two young persons, a man and a woman, in both of whom it would
appear that death ensued from puncturing the membrane. Where
fatal consequences are said to result from an operation which
heretofore has proved, to say the least of it, innoxious, it is of
very great importance that we should inquire into all the circum-
stances attending such cases, and the mode of performing the
operation. The first instance was that of a young woman, said to
be deaf in both ears for four years, the only history of whose case
is, that prior to that period she got a severe cold, with a swelling
of the glands of the neck ; but what was the cause of her deafness,
how it arose, what was the condition of the membrana tympani,
why the operation was performed, in what manner, by whom, or
with what instrument, we are not informed ; all we know is, that
** catheterism of the Eustachian tube was performed, and said to
fail; hence it was agreed upon that the membrane of the tympanum
should be pierced, a small piece being drilled out of the membrane
of the right side ;** but we are not told any other circumstances
attending the operation, nor who witnessed it. Pain and other
evidences of inflammation in the ear ensued, and profuse discharge
took place, but what the condition of the ear was we know not.
At the end of four months she died, with symptoms of diseased
brain ; and upon examination it was found that the dura mater
covering the petrous portion of the temporal bone was roughened
and softened in its texture, particularly near the internal auditory
foramen. The membrana tympani was entirely destroyed^ and the
lining membrane of the tympanum thickened and villous. Now,
while we are totally in the dark as to what the original condition
of this case was, it is manifest that some great violence must have
been done to the drum of the ear in the performance of the ope-
ration.

The second case is equally defective as to the cause of deafness

298 naFOBATioH of tub mbmbbana ttmpavi.

or the appearance of the ear, although the post-mortem examina-
tion was most interesting ; all Dr. Butcher states is, that the man was
deaf for twelve months previously ; that he then applied to a sur-
geon, and had his tympanum pierced ( ?) ; but why, or whether with
a gimlet or a punch, a trochar or a probe, we are not informed*
At first the hearing was improved, but then relapsed ; after some
time head symptoms set in, and the man died in the course of six
weeks. Upon dissection, evident traces of inflammation of the
brain and its membranes were discovered ; the dura mater in par-
ticular, covering the auditory portion of the temporal bone, was
rough and thickened, and a small abscess was discovered in the
anterior lobe of the brain, upon the same side on which the perfora-
tion was said to have been performed. In this case, however, the
original cause of the deafness, namely, a small tumour about the
size of a bean, lying on the auditory portion of the seventh pair
of nerves, was discovered. This was evidently a case in which
the operation never should have been resorted to. Dr. Butcher
deserves much credit for making those cases public, but it is to be
regretted that the statement of the surgeon who performed the
operation, whatever it was, was not obtained, nor the appearances
of the ear, both before and after the operation, described. (Th
cases are detailed in the Dublin Medical Press, April 1, 1846.)^

▲CCIDBNTAL PBBFOBATION OF THE MEMBBANA TTMPANI.

An aperture of the membrana tympani may occur from a
riety of causes. It may exist congenitally, it may happen by acci-
dent, such as a penetrating instrument, a foreign body in the
meatus, loud sudden noises, sneezing, coughing, or blowing the
nose, diving to any great depth, falls and blows upon the head,
all of which have been detailed under the head of wounds and
injuries of this structure, at page 220. We now come to inquire
into its condition when perforated by disease, the result of inflam-
mation, &c. An ulcer may eat its way through, and leave from
loss of substance a permanent opening ; but the most frequent cause
of perforation is otitis, or inflammation of the membrane, in com-
mon with the lining of the ca vitas tympani ; when in the suppura-
tion which ensues, the pent-up matter bursts through the inflamed

PEBFOBATION OF THE MBMBBANA TTMPAKI. 299

membrane as the nearest external outlet, and the case is then one
of otorrhoea. I do not think the membrana tjmpani is often per-
forated as the result of inflammation confined to its own proper
lamime.

In cases of perforation, the opening is generally opposite the
aperture of the Eustachian tube, which would rather lead us to
believe that it is caused by a burst or rupture of the membrane^
owing to a sudden jet of air striking against this thin portion of it
while in a state of inflammation and tension, rather than that it
was produced by either sloughing or ulceration. When a cornea
is about to perish in whole or in part from sloughing, hypopyum,
or penetrating ulcer, we have an opportunity of observing the pro-
cess from hour to hour. It is not so, however, in ca^es of inflam-
mation of the ear; we have seldom an opportunity of examining
the part until the mischief has occurred. When the disease hap-
pens during measles or scarlatina, the ordinary medical attendant
pays but little attention to the state of the ears, although the pa-
tient frequently complains of excruciating pains therein. He is
satisfied with attending to the state of the fever and the eruption,
telling the friends that the aural aflection can be easily rectified
after the patient's recovery. It must, however, be acknowledged,
that in many instances the general symptoms of the disease are of
such a threatening character, that both the physician and the friends
are well satisfied if the patient escapes with life. Nevertheless,
I cannot but feel, that an examination with the speculum should
be made in all such cases, and means taken to relieve the aural dis-
ease by the application of a few leeches, &c. I have frequently
saved eyes in patients labouring under small- pox, by employing
the ordinary remedies applicable to pustules in the cornea.

In cases of inflammation of the middle ear and membrana
tympani, we will generally find, upon examination, that the latter
is one uniform sheet of redness, without any appearance of point-
ing, sloughing, or ulceration; and, within a few hours after, the
patient will tell us that he is relieved of his pain by something
having suddenly burst in his ear, and then, upon inspection, we
find an opening in the membrana tympani.

In perforation, particularly if the aperture is large, the patient

300 fSaFOBATIOK OF TUB MBMBRAHA TTMPASI.

generally complains of some of the water getting into the throat
in syringing.

At page 139, I have already remarked upon the general cha-
racters and roost usual position of the aperture in the membrane.
Where there is no obstruction in the meatus, we can, by directing
a stream of strong sunlight through the speculum, easily detect
the rupture, unless it is either very small or valvular. If of long
standing, its edge is generally red and thickened, and the space
behind it is usually very dark, but we cannot be certain of the
precise colour unless the aperture is of a moderate size. When a
large portion of the membrane has been removed, as is often the
case in ears long affected with otorrhoea, we can with facility per-
ceive the colour of the mucous membrane of the tympanum, which
from its exposure, and the state of chronic irritation in which it
must be, is usually thickened, often granular, and always of a deep
bright red ; and, moreover, the edge of the aperture throws a dark
shadow upon the inner wall of the tympanum beyond, which we
can alter by changing the position of the head or the speculum,
in the same way that a shadow is seen between the margin of the
pupil, and an opaque lens behind, if the two are not in contact
In cases of extensive destruction of the membrane, where, upon
introducing the speculum, we merely observe a florid Ved vascular
surface, an unpractised eye may find it difficult to determine by
mere inspection whether the surface brought into view at the bot-
tom of the meatus is the surface of a carneous membrana tympani
or the inner wall of the tympanum itself. The difference can at
once be distinguished by passing down a fine probe,* and gently
percussing the surface we are looking at, and if it be that of the
tympanum, a delicate touch at once detects the difference of tex-
ture ; while, if the contrary, the patient is always conscious of some-
thing knocking against the skull, but generally complains less than
if the probe touched the membrana tympani. The part most usu-
ally presented is the promontory.

* When we have occasion to use a probe for examining the ear, it should be aboat
three inches long, fixed in a handle, have rather a large button on the end, and be rerj
slender for about an inch behind the extremity, so that it will bend with fS^ilitj afaonld
the patient more th« head in th« dfanetion of the instniment.

PEBFOBATION OF THE MEMBRANA TTMPANI. 301

When the membrane has been eaten away by ulceration, or so
much of Its lower portion destroyed by rupture or other circum-
stances as to cease to be a fixed point for the manubrium of the
malleus, the ossicula, or at least whatever remnant of them re-
mains, are drawn upwards and backwards, and generally present
with the remaining portion of the membrane a well-defined pro-
tuberance, generally whiter than the rest.

Where we have any difficulty in detecting an aperture, we
should direct the patient to force air into the drum, when the
squeeling, gurgling, or whistling sound produced by its transit
through the rupture will decide the question, — supposing the
Eustachian tube to be free, which, in some cases, it is not. When,
in cases of recent otitis, the meatus is thickened, and both it and
the external surface of the membrana tympani covered with a layer
of white macerated cuticle and flakes of discharge, it is sometimes
difficult, by mere inspection alone, to decide the question, particu-
larly if direct sunlight is not available at the moment. Some time
ago I described two diagnostic symptoms, one or other of which,
when present, are unfailing indications of rupture. If, on look-
ing into the meatus, even without a speculum, we see a single
globule of air entangled in the discharge which generally fills it,
we may rest assured that the tympanal cavity is open externally.
If we do not at first see this globule, and that we press upon the
root of the tragus with the point of the finger, we can generally,
if the tympanum is open, bring it to the surface. I suppose it is
forced up through the Eustachian tube in sneezing or coughing,
&c., and finds its way from the tympanal cavity to the surface of
the fluid. Sometimes the bottom of the meatus is filled with seve-
ral air-bubbles, which generally coalesce upon the introduction of
the speculum. Some years ago I was called to see a gentleman said
to be labouring under fever ; he was from the commencement ex-
tremely deaf, and had complained of violent pain in his ears and
head ; he had great heat of skin, loss of rest, a brown furred tongue,
great thirst, some intolerance of light, a very quick pulse, and
other febrile symptoms. Upon the fifth day a purulent discharge
was observed to issue from both his ears, when the attention of the
medical attendant was first attracted to the organs of hearing. I

302 PBRFORATION OF THE MEMBRANA TTMPAVI.

saw him upon the sixth day; he was then so deaf that he had to
be communicated with by writing. On examination I found se-
veral air-bubbles mixed with the discharge which poured from
his ears; and I at once stated to the practitioner in attendance,
what subsequently proved to be correct, that the case was one
of otitis, in which the tympanal membranes had given way to
allow exit to the pent-up pus. From the condition of the patient
at the time I saw him, it was not possible to make an accurate
examination, neither was such at the moment necessary. Two
days afterwards, upon removing the discharge, an aperture was
found in the antero-infcrior part of the membrana tympani, oppo-
site the Eustachian tube, on each side. These apertures subse-
quently closed, and the gentleman recovered his hearing. I have
remarked that a rupture of the membrane, produced, like this,
from otitis, heals more readily, and often without treatment, than
that produced by chronic otorrhoea ; the former being a rupture,
the latter an ulcer, and, consequently, attended with a greater loss
of substance. While correcting these pages, I was consulted by a
lady for deafness of the left ear. Upon examining the right, about
which she made no complaint, I found the membrana tympani
thickened and opaque, except one abnormally thin portion in the
centre, which was rather depressed beneath the surrounding sur-
face. Upon expressing an opinion that she must have had some
inflammatory action in that ear previously, she acknowledged that
nineteen years before, she had had a ** severe bcelding" which kept
her awake several nights, until relieved by a discharge of matter,
which continued to flow from her car for some months subse-
quently. I suppose the rent was filled up by the delicate bit of
membrane still apparent in the centre of the drum-head.

Another curious phenomenon, which has not, as far as I am
aware, been previously described by authors, is, — that, when the
membrane is perforate, and that an air globule exists at the bot-
tom of the meatus, we can, by keeping the eye steadily fixed upon
it, — and as its bright convex surface generally reflects the light, it is
easily seen, — perceive that it pulsates, and that its action is syn-
chronous with that of the heart and arteries. It is not an invariable
symptom, and the pulsation sometimes intermits. In order to sec

PEBFOBATION OF THE MEMBBANA TTMPANI. 303

in perfection, there ought to be but a slight coating of thin discharge
at the bottom of the meatus, and the globule from which the light is
thus brilliantly reflected should be either entangled in or opposite
the opening in the membrana tympani. In most of the cases in which
I have remarked it, the aperture was rather small, and situated in
the posterior part of the membrane. I have never seen it where
the opening was very large, or the membrane entirely destroyed.
It is an additional proof that the membrane pulsates, certainly in
disease, and probably in a normal condition also ; although we are
not in a position to detect its motion. (See additional remarks
upon this subject at page 218.) As already stated, the rupture
usually takes place in the anterior portion, and close to the open-
ing of the Eustachian tube ; sometimes it may be seen as a round
or oval hole, about the size of No. 8 shot, and appearing as if
punched out of the membrane. In other instances it occurs at the
anterior inferior edge of the membrane, in which case the lower
margin of the aperture is formed by the parietes of the canal and
cavity of the tympanum. In still rarer instances the rupture takes
place in the posterior division of the membrane, below, and some-
what behind, the point of the malleus. Sometimes the aperture
presents a kidney shape round the manubrium, which projects
into it like a peninsula.

The treatment of an aperture in the membrana tympani, and
the success which is likely to attend it, must depend upon its cause,
duration, and extent : the older, the less likely to heal, and if from
ulceration, it is also more unpromising than when it has taken
place from mechanical injury or the pressure of accumulated
fluid.

An aperture, even of considerable size, may exist in the mem-
brana tympani, without otorrhcsa, but upon the slightest acces-
sion of cold, otorrhcea will occur from the surface of the exposed
tympanal cavity. The prognosis is uncertain. I have sometimes
failed in healing very small apertures, while much larger oneshave,
to my surprise, closed, under treatment, in a very short time.

After a long and fair trial of several means proposed for heal-
ing apertures in the membrana tympani, I have come to the con-
clusion, that there is nothing like nitrate of silver. It will not,

«S04 PXBFORATIOH OF THB MBMBBAHA TTMPAMI.

however, answer to thrust a stick of lunar caustic, fastened in a
quill, down the meatus, for the purpose of touching any part of the
membrana tympani ; to be used with effect, the escharotic should
be applied upon the extreme edge of the aperture, or rather with-
in the ring of the opening, every second or third day, so long as
the part seems inclined to close, but the moment we perceive it
enlarging, a day or two after the application, we must desist. As
it is not always possible to reduce a pencil of nitrate of silver to
the requisite degree of fineness, I have, for several years past^
been in the habit of pointing probes and other instruments used
in minor surgery, with nitrate of silver attached to them, in the
following manner : — a portion of the caustic is to be melted to the
boiling point, in a small silver or platina ladle, such as that repre-
sented below, held over a spirit lamp. When the caustic has

become quite clear, the point of the probe or instrument to which
it is to be attached should be heated in the flame of the lamp, and
then dipped into the fluid caustic several times, until a suflEicient
quantity is taken up. By this means, we can point a needle with
caustic, should it be necessary to apply it to any minute part,
such as an ulcer on the eye, &c.* The instrument figured below
will be found very convenient for applying nitrate of silver to any

surface within the meatus. This port^-cawtic is about six inches
long, and consists of a silver tube, cut spirally for three-fifths of
its length, and having an aperture in the side, or a hollow at end.
When about to be used, its extremity should be coated with caus-
tic, as already directed. The elastic spring prevents any injury

* Dr. M'Donnell, of Montrea], formerty of Dablin, wrote ao article in the Medical
Journal of that dtj some jears ago, to show that I was not the original inventor of thb
ingenioos application of this very useful remedj, and that Dr. Morgan of this city was
the person to whom the credit belongs. When, in January, 1S44, I first recommended it,
I feel sure that, if I had remembered Dr. Morgan's suggestion, I would hare ""yynrtiMied
it, as I have all my life laboured to " render tribute to whom tribute is due ;'* and I there-
fore take this opportunity of rendering my townsman due credit for the suggestion.

PEBFO&ATION OF THE MEMBBANA TYMPANI. 305

to the car from the starting of the patient, and can also be bent,
so as to be applied with ease to any part of the auditory canal.
When granulations sprout from a perforation in the membrane —
which is very rare, unless the rupture occurs immediately adjoin*
ing its edge — this mode of applying caustic will be found very
e£fectual, as well as for the eradication of small polypi ; but I
have never yet seen a polypus attached to the membrana tym-
pani.

When the membrana tympani is perforated, and that we touch
it, or a polypous growth, or sometimes even an abraded spot upon
the surface of the meatus, with solid nitrate of silver, it is, in many
cases, tasted in the mouth almost immediately, but only on the
side to which it has been applied. Patients say, '* they feel the
impression of the caustic running down along that side of the
tongue, but not reaching the lip." I never knew this peculiarity,
except where there was a hole in the membrane. Is it transmit-
ted by continuity of mucous surface, or by means of the chorda
tympani ?

The following case. No. 2 in the Registry, of chronic thick*
ening of the left, and total loss of the right, membrana tympani,
will be found illustrative of the foregoing observations : —

E. S., a female, aged 25, suffered from disease of the ears since
she had scarlatina, three or four years ago ; has had *' a running**
from one ear, but never experienced any pain on either side, and
never had medical advice. A constant buzzing noise is present
in the left ear ; none whatever in the right. Hearing distance on
the right side, five inches ; on the left only on pressing the watch
to the external ear ; hears the watch well on placing it between
the front teeth. Upon examination, we find chronic inflamma-
tion, attended with muco-purulent discharge, in the right ear. On
bringing the bottom of the meatus auditor! us into view, we per-
ceive a smooth, deep-red j moist, and irregularly concave surface:
this is the inner wall of the tympanum, the mucous membrane co-
vering which, by being so long exposed to the atmosphere, has
assumed this peculiar florid and villous appearance. The eye in-
forms us that we are not looking at the membrana tympani ; the pe-
culiar curve of the surface that meets the view, the hue of colour,

T

806 PBBFOEATIOH 07 THE MEMBBAHA TYKPAHI.

and the great depth at which it is placed, would, even if one were
not well acquainted with the appearance, at once lead us to say
that the membrane had been removed ; and, on passing down a
fine round-headed probe, it knocks against the bony protuberance
of the promontory. The spot where the probe touched has be-
come of a much deeper red, and the patient says she ezperienoed
a sensation as if something was knocking loudly against the side
of lier head. Towards the upper and posterior side there is a
white projection, the displaced malleus, from which a shadow is
thrown upon the red surface of the tympanal cavity. The sha-
dow thrown from it proves that it is not in contact with the deep
surface we are looking at : in the same way as the shadow cast
by the pupillary margin of the iris tells us the position of the opa-
city, and other circumstances of great importance, in a practical
point of view, in cases of cataract. Towards the lower and ante-
rior edge of the cavity may be observed a spot darker than the
rest, — the aural opening of the Eustachian tube,— -but the patient
is unable to pass air through it. When this tympanal membrane
was destroyed we know not ; probably an aperture occurred in it
during the scarlet fever, from which she suffered at the time her
deafness came on, and, by ulceration, it has since extended. I
am inclined to think this has been the process ; for she says the
discharge under which she formerly laboured, and which was
so great as to pour out of the external meatus and soil her
dress, has of late considerably lessened, and is now very slight,
and about the consistence of made starch. This accords with
my experience of those discharges. In cases of polypus, with-
out any aperture in the tympanal membrane, the discharge is
always profuse, and usually purulent; where there is an aper-
ture in the membrane, it is, generally speaking, not so abundant,
but more mucous ; and where the membrane has been almost en-
tirely removed, as in this case, the discharge frequently lessens.
Sometimes there is scarcely sufficient secretion, and patients are
in the habit of moistening the ear with a drop of water applied
with the end of the finger. I know a gentleman who does so
every day after dinner when he wishes to hear well, and he has
an aperture in his membrana tympani. As already stated, this

ARTIFICIAL KEMBRANA TTMPAVI. 307

patient has no noise upon this (the right) side. Where the mem-
brane has a large aperture in it, or has been completely removed,
I have generally, but not invariably, observed, that there is no
tinnitus aurium, or, if such existed upon the first accession of
deafness, it ceases as soon as the membrane has become so much
destroyed as in this case, unless it had been originally cerebral.
Therefore it is that some persons have derived relief from this
most distressing symptom by having the membrane perforated,
although the removal of the deafness could not be expected.

This woman hears at five inches distance upon the right side ;
but she hears the voice better than other persons who possess a
hearing distance by the watch of some inches more : this is worthy
of remark, and applies to a vast number of deaf cases. Some per-
sons are better able to understand the purport of discourse firom a
natural quickness of comprehension, and will maintain a conver-
sation although they cannot hear the watch at two inches distance ;
while others who hear the watch at three times that distance ex-
hibit a dulness of general hearing that is quite remarkable. I
have observed that, when once the tympanal membrane has be-
come permanently open, the larger the aperture, the greater the
amount of hearing, provided no further mischief has taken place,
and that there is a slight ring or circle of the membrane still re-
maining.

Artificial Membrana Tympard, — A complete cure for deafiiess
arising from an aperture of the tympanal membrane, by passing
a portion of wool or raw cotton, moistened with some fluid, into
the bottom of the meatus, was published in July, 1848. I became
aware of the fact about eight years ago, through a lady resi-
dent in Clonmel, who discovered it, she told me, by accident.
Considering hers an isolated case, and having my attention di-
rected particularly to other subjects at the moment, I thought no
more about the matter then. The lady informs me, in answer to
a recent communication, that the disease in her ears originated in
what she styles brain fever, eighteen yfttrs ago, but that the phy-
sicians whom she consulted told her that her aural affection was
merely nervousness, and that the drums of her ears were quite
unaffected. *' Suffering,** she says, *< so dreadfully from deafness,

y2

308 ARTIFICIAL MEMBBAHA TTHPASI.

and a suffocating feel about my head, I resorted to many experi-
ments. At last I was recommended to try a piece of fiit bacon,
toasted over a candle, and then put into the ears. I used it for a
long time, but eventually I was obliged to discontinue it, as it
hurt me very much. I then'dropped oil into my ears instead, and it
for a while enabled to hear, but in an hour or two afterwards I
used to be as deaf as ever ; so I naturally thought that, by pattiiig
a little wool with the oil into my ear, and thus keeping up the
moisture, it would answer the purpose. This I tried, and found
it most efficacious. I must, however, have it settled in one par-
ticular spot in my ear, or it would be quite useless, and were I to
take it out I would not hear a word. I generally arrange it with
a large pin or bodkin, and, when fixed properly, I have no occa-
sion to change it for three days together." — A. Mc S.

To Mr. Yearsley we are, however, indebted for making this
valuable discovery known, as already stated at page 35; and al-
though Deleau and others have claimed acquaintance with the
fact, it is manifest that they made no use of it* The subject is
one that has lately engaged, and very justly, much attention, and
I have recently verified in numerous cases the opinion which I
have on a former occasion expressed of its value.

A gentleman, about fifty years of age, caught a violent cold
by being much exposed during the night air among some of the
snowy mountains and glaciers of Switzerland a year and a half
previous to the time I saw him. He was attacked with dull ach-
ing pains in his ears, attended with considerable deafness. He
said — and being a person of great intelligence and some scientific
acquirements, I was constrained to believe his statement — thati
upon applying for advice in one of the large towns in Switzerland,
a mixture containing muriatic acid was prescribed for him, in
order '^ to alleviate the pain and stimulate the drum of his ears."
Shortly after the first application, which, unfortunately, was made
on both sides, he had a violent attack of ear-ache, which, he states,
^'nearly set him mad,** but that he got relief as soon as something
burst in his ears, and that a discharge was established. Ebtving

* See Medical Times for 12tb April, 1851, p. 412.

ARTIFICIAL MEMBBANA TTMPANI. 909

heard of the glycerine-and-cotton remedy, he applied it, and suc-
ceeded once, but never after, in gaining relief Upon inquiry, I
found that he had completely filled the meatus with a plug of
wool and glycerine. On examination, I found that the tympanal
membrane had been altogether removed upon one side, and but
a slight remnant of it remained upon the other. He had a good
deal of discharge ; no noise ; but he was so deaf that one required
to shout to him ; and he came to me to recommend him some sort
of hearing-trumpet. The mucous membrane of the tympanal ca-
vity and the meatus were in a state of chronic inflammation,
which, being lessened by the application of a solution of nitrate
of silver and other means employed for a few days, I introduced
bits of moistened cotton in the manner previously described. His
hearing was instantaneously restored ; and, having taught him
after a few visits how to manage the application himself, be was
again able to join society almost as well as ever.

Highly valuable, however, as, no doubt, this remedy is, it is, in
its application and usefulness, variable. In some cases what it will
effect is quite marvellous, — almost instantaneous restoration to
comfortable hearing ; but, in other instances, it does not succeed so
well, or even at all. The cases in which it is most effectual are those
where there is a very large aperture in, but not a total destruction
of, the membrana tympani. It requires some tact to hit off the exact
position in which to place the bit of cotton ; but, the moment it is
done, either by the practitioner or the patient, the hearing is re-
stored. It should be made to fit on or into the aperture in the mem-
brane, not completely to block up the meatus, nor to press against
the inner wall of the tympanum. It ought to be passed down with
a fine forceps or probe, and patients should be taught how to intro-
duce it themselves ; the lady by whom I first saw it employed al-
ways carried a bodkin, a little fine wool, and a bottle of oil, for the
purpose. I do not think it matters much what the fluid is ; I ge-»
nerally use fine oil, and, after the bit of cotton is saturated with
it, I press it gently between the fingers. As there is always some
discharge from the exposed mucous membrane in these cases, a
sufficient moisture is kept up for two or three days ; but the wool
or cotton should be removed from time to time, according to the

310 ARTIFICIAL MBMBBAHA TTMPAn.

patient's own sensations, and never allowed to remain in longer
than three or four days. If there be much discharge present^ the
wool or cotton may require removal daily. It is astoniahing with
what adroitness a patient will sometimes hit off the necessary po-
sition of the cotton, even after the practitioner has failed to adjust
it. Notwithstanding some ingenious attempts at explanation, we
still require a feasible solution as to how this remedy acts.

Mr. Toynbee has recently recommended a thin plate of vulca-
nized India rubber or gutta percha, attached to a wire stem, as an
artificial tympanic membrane, in lieu of the wool or cotton re-
medy.* I have no experience of it ; but I doubt its general ap-
plicability.

In the foregoing chapter I may to some have appeared prolix;
but, upon a subject comparatively so new in English literature,
BO little studied, and consequently so little understood by prac-
titioners in general, it was not possible to explain my meaning
vnthout entering into minute descriptions. Moreover, from the
circumstance of the membrana tympani being the part most easily
examined, being that most frequently affected, and, consequently,
affording the safest means for diagnosis either for deafness arising
from affections peculiar to itself, and confined to its own structure,
or which it exhibits in common with other and deeper-seated
structures similarly diseased, it frequently affords us not only the
surest but the only faithful indication for forming an accurate diag-
nosis. If aural diseases were as attentively studied in these king-
doms as ophthalmic or obstetric affections, then would the length-
ened description of cases be unnecessary ; but where do we find,
throughout the whole circle of our periodical literature, half-a*
dozen well observed and accurately noted cases of disease of the
ear in a twelvemonth ? Faithful observation and clinical records
of disease are now more required in this than in any other branch
of medical science.

• See Medical Hmes and Gazette for Febniaiy 12, 1858.

311

CHAPTER VI.

DISEASES OF THE MIDDLE EAR AND EUSTACHIAN TUBE.

Anatomy of the Cavitas Tympani — Apertures, Oasicula, and Investing Membrane.-^Th*

Eostachian Tube and Tonsils. — Congenital Malformations of the Middle Ear.

Wounds and Injuries; Hemorrhage and Serous Effusion. — Inflammations: Acute
Otitis ; Otonhosa ; Subacute Otitis ; Exanthematous and lyphoid; Acquired Dumb«
ness; Fadal Paralysis. — Rheumatic Otitis ; Periosteal ; Carie& — Diseases of Mastoid
Cells. — Affections of the Ossicula. — Morbid Growths in the Tympanum ; Polypus ;
Exostosis. — Catarrhal and Chronic Otitis : Ablution, Fumigation, and Bougie Explo-
ration of Tympanum. — ^Malignant Fungus. — Diseases of the Eustachian Tube ; Fo-
reign Bodies in ; Inflammation ; Obstruction.— Throat Deafness.-— Enlarged Tonsik
and Cleft Palate.

ALTHOUGH I have separated the diseases of the Eustachian
tube firom those of the cavitas tympani in the Nosological
Table, in accordance with the anatomical basis observed in their
general division ; still, in a pathological point of view, these two
parts may as fairly be classed together as the diseases of the middle
ear and the mastoid cells.

The middle division of the auditory apparatus, the tympanum
or cavitas tympani, is that space between the membrana tympani
externally, which separates it from the auditory tube, and the
outer wall of the internal ear or labyrinth. It resembles the form
of its external septum, but is rather more irregular in its cir*
cumferential boundary. It is somewhat wedge-shaped, being nar-
row below and broad above, owing to the oblique position of the
membrana tympani, and measures about three-eighths, or from that
to half an inch in its longest diameter. In the dry bone it has five
special outlets, — externally into the osseous meatus; — internally
by two small apertures, which communicate with the labyrinth,
called from their shape the round and the oval window, — two pro-
ceeding from the circumference ; of these, that anteriorly, and a
little below the middle horizontal line, is the entrance of the Eusta-
chian tube, which communicates with the throat ; and one or more
openings lead in the adult into the mastoid cells superiorly and

312 AVATOMT OF THE CAYITAS TTMPAVI.

posteriorly. Viewed from without, by making a section of the tem-
poral bone immediately beyond the groove for the attachment of
the membrana tympani, we observe upon its inner wall a projectioii
of densely hard bone dividing the two apertures already alluded
to, both of which are placed in the posterior half, and consequently
immediately opposite the external outlet of the osseous auditoiy
canal and the posterior vibrating portion of the membrana tympam.
This protuberance is the promontory caused by the projection of
the cochlea : the inferior opening is the fenestra rotunda, somewhat
triangular in shape, and in the recent state closed by a delicate
membrane analogous to the membrana tympani, and which may be
called the internal drum-head, which separates the tympanum
from the extremity of the cochlea, and hence called the fenestra
cochleae. As this membrane serves to transmit vibrations of sound,
and is the only barrier to the escape of the fluid contained within
the labyrinth, it is manifest that any interference with its func-
tions, any alterations or organic changes in its structure, or its to-
tal destruction from sloughing, ulceration, or caries of its bony
attachment, must be attended with considerable impairment^ if
not total loss, of hearing. When the tympanic cavity is exposed
by extensive destruction of its outer membrane, we do not see the
little membrane ofthe cochlear fenestra; the whole looks oneuni«
form red surface, and in this state the physiology of hearing has not
yet been satisfactorily explained ; but I presume that the waves of
sound impinge directly upon this membrane, and sensations are thus
conveyed to the internal ear. That the membrane vibrates is proved
by experiment, and one use of it may be to allow the fluid con-
tained within the vestibule, when pressed upon by the base of the
stapes — covering, like a lid, the fenestra ovalis — to bulge a little
into the cavity of the tympanum. But that this latter must be a
secondary object is proved by the amount of hearing possessed by
persons who have suffered from extensive destruction of the mem-
brana tympani, or have even lost some ofthe ossicles.

The superior opening is, as its name implies, oval or ovoid
for the reception of the base ofthe stapes, which fits into it some-
what like a stopper, or the piston of a cylinder, and is attached
to its circumferance by a ligamento-fibrous membrane, which
allows a double motion to the small bone which it surrounds^ a

AHATOMT OF THB CAYITAS TTMPANI. 318

stopper-like one by which it is forced towards the cavity of the
vestibule, with which this opening communicates, — and a lateral
or oscillating one by which each of its extremities can be made to
press inwards in turn.* The surface of the promontory is grooved
for the ramification of the tympanic branches from the glosso-pha-
ryngeal nerve. Traversing the superior wall of the tympanum, im-
mediately above the fenestra ovalis, is the aqueduct of Fallopius
for the transmission of the facial portion of the seventh pair of
nerves, which projects somewhat into the roof of the tympanic ca-
vity, and the relations of which have already been remarked upon
at page 214. Posteriorly and immediately below this conduit of the
facial, we observe a little conical eminence called the pyramid, in
the apex of which there is a depression leading into an opening
which gives insertion to the stapedius muscle.

From the large sinus in the roof of the tympanum, or some*
times by one or two openings in addition, the mastoid cells commu-
nicate freely with the cavitas tympani, and it is of great importance
to bear this communication in mind, when inflammation attacks
the tympanum, which space, as well as these mastoid cells, are
separated from the cavity of the cranium by a thin and often de-
licate lamina of bone, pierced by several small apertures for the
transmission of vessels to the dura mater, which adheres intimately
to the superior surface of the bone at this place.

Anteriorly and somewhat inferiorly the whole side of the
tympanal cavity, from the attachment of the membrana tympani
in front to the root of the promontory behind, may be seen the
smooth trumpet-shaped entrance of the Eustachian tube ; and not,
as is described in books, commencing by a small aperture ; on the
contrary, it is the widest part of the bony portion of that canal.
Along its posterior margin, somewhat above the middle, a delicate
concave shelf of bone stands out, which forms the floor of a canal,

* See the splendid work of Professor Hyrtl of Vienna, upon the Comparative Ana-
tomy of the Ear, " Vergleiehend'antUcmUehe UnteTtuehvngen uber dai innere Geh'ororgan
det Mensehen vnd der SaugetkiereJ* See also, in addition to the various works upon
Anatomy, and Mr. Wharton Jones' Eosay in the Cyclop»dia of Anatomy and Physiology,
the recently published paper by Mr. Toynbee " On the Functions of the Muscles of the
Tympanum in the Human Ear," in the British and Foreign Medlco-ChiruTgical Review
for January, 1868.

814 AVATOMT OF THE CATITA8 TTXPAVI.

completed by fibrous membrane, through which the tenaor tympani
muscle plays. The length of the bony portion of the Eustachian tabe
is about half an inch, and of an irregular elliptical figure, sometimfla
resembling a mere slit, and seldom admitting, even in the dry
bone, anything larger than an ordinary-sized dressing probe» and
certainly not capable of giving transit to the great majority of the
bougies and other instruments recommended by aurists to be passed
through it for the purpose of clearing it, or of exploring ( ?) the
cavitas tympani.

The parts contained within the tympanum are : — the oesicala
auditus, the muscles by which these bones are moved, and the
chorda tympani nerve, which in its circuitous course traverses the
upper part of this cavity.

This chain of small bones has three points of attachment, — the
membrana tympani, and the fenestra ovalis, between which they
stretch, and the walls of the tympanum, which afford them sup-
port. They consist of the malleus or hammer, the incus or anvil,
and the stapes or stirrup ; to which some anatomists have added
a fourth bone, under the name of the orbicular, but which
is now believed to be a portion of the incus. All these bcmes,
when placed together, form an arched chain of levers, extending
across the upper and back portion of the tympanal cavity, and
which by their motions serve to convey vibrations of sound from
the membrana tympani, to which they are attached externally,
to the fenestra ovalis, where the inner leg of the arch is fastened;
and also to place both the membrana tympani and the membrane
of the fenestra rotunda in particular states of tension or relax-
ation, whereby they can be affected by sounds more or less
grave or acute. For this latter purpose their mechanism is under
the control of muscles probably of the voluntary class. The mal-
leus or hammer consists of a body fitted into a corresponding sur-
face in the incus ; a head rising into the tympanic sinus above
the attachment of the membrana tympani ; a manubrium or han-
dle stretching down between the laminae of the latter structure,
to which it gives insertion and support, as already explained at
page 215 ; a tubercle between the body or neck and handle,
which is always recognisable through the membrana tympam;

▲KATOHT OF THE CAVITA8 TYMPANI. 815

and a long slender process, which, springing at a right angle from
the rest of the bone, crosses the tympanal cavity obliquely from
behind forwards, and a little downwards towards the Glasserian
fissure, where it is attached near the edge of the tympanic ring.
The incus is also an irregularly-shaped bone, not inaptly resem*
bling a bicuspid tooth; the crown of which is articulated to a
corresponding surface upon the malleus, and the two fangs or
crura are attached, the shorter by ligament to the roof of the
tympanum near the orifice of the mastoid cells, and the long
process, extending downwards nearly parallel with the handle of
the malleus, but towards the inner wall of the tympanum is arti-
culated with the head of the stapes. The stapes itself, which in
its similitude to a stirrup is perhaps the most exact resemblance
which any portion of anatomy has yet derived a name from, is
set by its base into the opening of the vestibule, and thus com-
pletes the connecting links between the external and internal ears.
From the anatomical relations of this bone, and its acting either
with an intervening membrane — the membrana vestibuli of for-
mer anatomists— or simply by ligamentous connexions to the edge
of the foramen ovalis, as the principal barrier to the escape of the
contents of the vestibuli, the semicircular canals, and even the
cochlea, its total destruction or removal must be attended with
irreparable loss of hearing, unless the foramen ovalis becomes filled
up with a new or false membrane, and that the labyrinthine fluid
re-accumulates. Fortunately, this little bone is less frequently lost
in otorrhoea than either of the others. The various articular sur-
faces between these minute bones are incrusted with cartilages,
provided with synovial membranes, and held together by minute
ligaments.*

The muscles which move these small bones are the tensor
tympani and the stapedius ; the former of which arises in the osseo-

* It is said that at birth the ossicles are as large as in the adolt The stapes, sajt
Mr. Williams, ** weighs, when dried, one thirty-second of a grain." This is a great exag-
geration. I find that from fire to six of these little bones weigh, in the diy state, a grain.
The same author, in that Treatise for whidi the Umyersity of Edinburgh awarded a gold
medal, states that " the membrana tympani ia covered with wax, which is for the pur-
pose of modifying sound" I !

816 AVAToinr of the cavitas tthpavi.

cartilaginous canal above the Eustachian tube already deacribed,
and, crossing the upper portion of the tympanum, is attached to the
malleus near the junction of the tubercle and handle, which bone
it draws inwards and forwards, and so assists to render the mem-
brane, which it supports, concave externally; but whether that
structure is really rendered more tense or more relaxed by this
action, remains for further investigation. It would appear from
observing the mechanism of the chain of bones extending between
the external and internal walls of the tympanum, that the actioo
of the tensor tympani must, by drawing the malleus inwards, af-
fect the position and motions of the stapes upon or within the
fenestra ovalis. If, as anatomists suppose, the action of the ten-
sor tympani assists indirectly to press the base of the stapes in-
wards towards the cavity of the vestibule, it is manifest that it
must affect the fluid of the labyrinth, and by its means press out-
wards the membrane of the fenestra rotunda. But if the long
leg of the incus, through which the motion of the tensor tympani
is conveyed to the top of the stapes (instead of pressing point-
blank against that bone in its ordinary horizontal position, so as to
bear upon it like the piston rod of a cylinder), presses it obliquely,
and gives its base an oscillatory motion, it is as likely to relax
the membrane of the fenestra rotunda by withdrawing the pressure
of a portion of the stapes from the fenestra ovalis. And die ob-
lique position at which the incus articulates with the stapes
renders this probable ; so that it is only by a combined action of
the tensor tympani and stapedius muscles that the base of the
stapes can be pressed directly inwards against the fluid of the
vestibule. The stapedius muscle, which is much shorter and
smaller than the preceding, arises within the aperture of the py«
ramid, and is inserted into the head of the stapes. By some it is
supposed to act as an antagonist to the tensor tympani; and
this opinion receives support from the fact, that it is supplied by
a branch from the facial nerve, while the latter receives its ner-
vous supply from the otic ganglion ; but, says Mr. Wharton Jones,
** the principal nerve of the tensor tympani is derived from the
pterygoid nerve of the third branch of the fifth." Its action is
to draw the stapes backwards, and consequently elevate that por-

AHATOHY OF THE EUSTACHIAN TUBE 317

tion of its base contained within the anterior edge of the fenestra
ovalis. It is remarkable, that both these muscles have their ori-
gin within fine bony canals which, projecting somewhat into the
tympanal cavity, serve to give them an exact and special di-
rection ; and, as particularly occurs in the case of the tensor tym-
pani, by means of pulley-like tendons, slightly to alter the ori-
ginal direction of their course. Both muscles acting together, the
tensor tympani, by pressing the anterior edge of the base of the
stapes, and the stapedius its posterior extremity, must press it in-
wards, and so affect the fluid of the labyrinth and the membrane
of the fenestra rotunda.

The action of these bones and muscles is twofold — when vi-
brations of sound impinge on the mem brana tympani to convey its
minutest motion across the tympanum, and communicate such
to the labyrinth ; and also to act as the analogue of the iris, and
thus, by regulating the state of tension of the different structures
thrown into vibration, to control the amount of sonorous undula-
tions that pass to the labyrinth. With respect to the problem
regarding the voluntary action of the tympanic muscles, Mr.
BUcher writes : as they ** are supplied from the two sources, — from
the voluntary system by the portio dura, and from the ganglionic
by the chorda tympani and the otic ganglion, — is it not probable
that they may be of a mixed character, acting involuntarily when
the acoustic nerve is over-excited, or when the mind is otherwise
engaged, and attention not directed to the protection of the mem-
brane and of the ear in general ; and being influenced by voli-
tion, when the individual is desirous to increase or to diminish
his mental perceptions?** Mr. Toynbee, who has lately written an
ingenious article upon the subject (see Note, page 313), says:
'^ I think it may be fairly inferred, that the function of the tensor
tympani muscles is to protect the membrana tympani and the
labyrinth from injury during loud sounds ; while the stapedius
muscle places these structures in a position to be impressed by
the most delicate vibrations; and it would appear to be brought
into action during the process of listening.**

The Vidian nerve, after leaving the portio dura near its exit
from the aqueduct of Fallopius, enters the tympanum, where it

318 AVATomr of thb mastoid cxlu.

leceiTee the name of chorda tympani, by a special opening behind
the posterior margin of the tympanic groove, and forming an arch
close to the roof of the cavity, runs to the canal beside the fissure
of Glasser ; passing in this course between the handle of the mal-
leus in front and the long process of the incus behind. In expltr
nation of the peculiar tortuous course of this most remarkaUe
nerve, and its final association with the gustatory, submaxillaiy,
and dental supply. Professor Harrison says: — ^This connexion,
also, so close to the tympanum, which contains the ossicula and
musculi auditus, may be designed to impart the twofold proper^
ties of sensation and of motion to this apparatus, through the fila-
ments which connect the portio dura subsequently to the tympanic
plexus: thus the organ of hearing, like that of vision, will befiir-
nished with the three sets of nerves, one for special sense, one for
sensation, and one for motion.** (Dublin Dissector.) A familiar
example of one of the phenomena resulting from the course of this
curious nerve is, that of having the teeth *'' set on edge** on hear-
ing the filing of a saw, or any other similar grating sound*

The mastoid cells are so irregular both in size, number, and
arrangement, that no special description of them can be givim;
those nearest the tympanum, one or two in particular, are the
largest; in a pathological point of view, it is sufiicient to know
that they communicate freely with the cavitas tympani, and are
lined by a continuation of its investing membrane; they also sur-
round the floor as well as the posterior wall of the tympanum ; and
the former locality is frequently seen covered with small cells in
the dried bone. One of the best methods of displaying the form
and continuity of these cells is by a cast taken in type metal, when
they resemble a bunch of grapes attached by the stalk to the por-
tion filling the tympanum. Anatomists and physiologists have
not yet offered an unobjectionable theory to account for the ex-
istence of the mastoid cells, which are only developed in adult
life. The generally received opinion is, that they permit a
greater degree of resonance in the cavity of the tympanum than
would otherwise occur. It has been advanced that, by afford-
ing a greater amount of surface for the expansion of the mu-
cous membrane of the tympanic cavity, like the Schneiderian

AVATOMT OF THE EUSTACHIAK TUBE. 319

membrane in the ethmoid cells and frontal sinuses, they thereby
increase the powers of hearing; but we have no warrant for be-
lieving that the membrane is endowed with that faculty. I am
inclined to think that, independent of their mechanical use in
affording lightness with stability to the mastoid process, they act
as a diverticulum or reservoir for the air contained in the tympa*
nic cavity ; and their being placed nearly opposite the entrance
of the Eustachian tube rather favours this idea. If there was
not some such space in which air might be occasionally compressed,
I believe the membrane would be ruptured in forcible expirations,
— such as sneezing, coughing, or violently blowing the nose, — as
well as sudden loud noises acting from without, much more fre-
quently than usually occurs. And, when the membrane bursts
during the progress of otitis (which generally occurs during a vio-
lent expiration), it must be remembered that the mastoid cells are
either blocked up by the inflammatory process or filled with pus.
The Eustachian tube consists of an osseous and a cartilaginous
portion ; the average length of the former is about half an inch,
in width it is about the eighth of an inch from above downwards,
and not more than the tenth from before backwards, or from side
to side. This tube is separated from the carotid canal by a very
thin plate of bone. The membrano-cartilaginous portion is fully
an inch long ; it is attached to the notched irregular extremity of
the osseous part in the petrous portion of the temporal bone, and
also to the edge of the sphenoid. This is generally the narrowest
part of the tube, and from thence in its downward and inward di-
rection to its gutteral orifice in the pharynx it gradually enlarges,
but more particularly at its lower extremity. It thus resembles a
straight trumpet, the small enlargement of the mouth-piece being
at the tympanum, and the larger bell-shaped extremity opening
behind the posterior nares, with its lower margin a little below
the floor of that aperture. Viewed in the recent state, by mak-
ing a central vertical section through the base of the skull,
mouth, and pharynx, the lower opening of the Eustachian tube
presents an obliquely upright elliptical slit or fissure about half
an inch long, with thick, round, and slightly prominent lips.
Placed thus behind, and so much above the hard and soft palate.

820 AVATomr of thb cayitis ttmpavi.

it is manifest that the tonsils, even when enlarged, cannot press
upon its partially open mouth without first coming in contact
with the palate plate, and lifting upwards and backwards the ve-
lum, which, it is well known, never occurs. When the tonsils are
in a state of chronic enlargement from hypertrophy of their folli-
cles, thickening of their mucous membrane, and cheesy, calcareouSi
or other abnormal deposits within their structure, — they first pro-
ject towards one another, and consequently encroach upon the
size and shape of the isthmus faucium, then towards the cavity ct
the mouth, and afterwards into the bag of the pharynx. 1 have
never seen nor heard of a preparation showing the greatest possi-
ble degree of enlargement of the tonsil, in which it pressed upon
the trumpet-mouth of the Eustachian tube. Anatomists will,
therefore, find it as difficult to believe that enlarged tonsils pro-
duce deafness as practical surgeons to believe that their removal
can in any way relieve loss of hearing. Even in cases of cynan-
che tonsillaris, when so large a collection of matter forms in the
gland that suffocation threatens, there is no deafness. When deaf-
ness coexists with enlarged tonsils, I believe it is produced by the
thickening of the mucous membrane extending into the Eusta-
chian tube, or into the tympanum. The direction of the Eustachian
tube is forwards, inwards, and downwards, towards its fellow on
the opposite side, so that if a line passing through the centre of
each was prolonged, it would cross that of the other side at an
acute angle about the middle of the palate bone. It is partially
fixed by the hamular process and the levator palati muscle ; and
its connexions with the muscles of the pharynx must always ren-
der it liable to alteration in the acts of mastication, deglutition,
coughing, sneezing, or yawning. It must not be supposed that
the Eustachian is a tube always open, no more than the urethra;
although provided with cartilage, its sides are, in the middle third
of its course at least, usually in contact.

The great gastro-pulmonary mucous membrane, passing up over
the nose and pharynx, is continued into the Eustachian tube, at
the orifice of which it presents the same characters with that lin-
ing the mouth and throat, being highly vascular, and studded
with numerous fine glands, which secrete a plentiful supply of the

AKATOMT OF THE CAVITAS TTMPAVI. 321

usual fluid poured out from that structure ; and we can, therefore,
understand how affections of these membranes may, by continuity
of surface, extend into the upper portion of the tube and middle
ear. As the membrane advances towards the osseous part of the
tube, where it becomes periosteal and fibro-mucous, its characters
change : it is less red, presents fewer follicles, is remarkably fine ;
and the villi on its surface are supposed to possess that peculiar vibra-
tory motion which Purkinjie and Valentin discovered some years
ago. As it approaches the upper extremity of the tube it becomes
still more pale and delicate until it enters the cavity of the tym-
panum, in the healthy normal state of which it is of such smooth-
ness and tenacity as to be demonstrated with difficulty ; yet in
disease or by exposure, as every practical aural surgeon knows,
it becomes in succession highly vascular, villous, thickened, infil-
trated, pulpy, and even sarcomatous, bleeding freely, secreting
mucus largely, sometimes pouring out pus in an incredibly short
space of time, and throwing out fungous granulations, &c. In the
cavity of the tympanum it spreads over every surface, and is re-
flected round the various bones, ligaments, muscles, and nerves,
and over the membranes closing the external auditory and cochlear
apertures ; and also extends into the large series of mastoid cells ;
so that, like the superficies of the peritoneum, it presents, on a
careful consideration and examination of the parts, a much more
extensive surface than would, at a superficial glance, appear. In
anatomical characters, as well as in pathological phenomena, the
lining of the lachrymal passage has many points of analogy with
the tympano-Eustachian mucous membrane, which those fami-
liar with the structure, relations, and diseases of both will upon
reflection perceive, and may in treatment follow out. In the nor-
mal state the lining of the tympanic cavity presents a smooth, dry,
but polished surface, of a greyish-white colour, somewhat like the
external aspect of the membrana tympani, but frequently present-
ing, as 9k post-mortem appearance, a slightly pinkish hue: being in
a healthy state transparent, its colour must be that of the bone
beneath. Like all mucous surfaces, it exhales moisture, but the
quantity must be so slight, and the fluid so very fine, that it finds
a ready outlet through the Eustachian tube. In the fcBtus the mem-

z

322 AVATOICT OF THE CATITA8 TTllPAm.

brane is highly vascular and secretes mucus^ which is often found
filling up the tympanum. Perhaps the variety in the period of au-
dition may depend upon the more or less rapid absorption or excre-
tion through the Eustachian tube of this mucus; while its presence
in the* very early periods of life may be useful in protecting the in-
ternal ear and auditory nerve from the injurious influences of
sound in their then delicate condition, — in the same manner
as the closed eye-lids of cats and some other animals for the first
eight or nine days after birth protect them from the injurions
effects of light.

I have thought that the increase of the lower jaw at the period
of the first dentition (the usual time when infants are first attracted
by sounds), by its condyle pressing on the cavity which forms the
lower boundary or floor of the tympanum, serving to enlarge it by
pressing upwards and outwards the tympanic ring» and also by the
development of the dental organs not only altering the position
of the maxilla itself, but calling into action a hitherto but Kttlc
employed set of muscles, — might so change the position and cali-
ber of the inferior portion of the Eustachian tube as to aflTord a
ready outlet for the contents of the tympanum. In support of this
view, I may mention that, in many cases of partial deafness, as well
as defective speech, and in some instances of stammering, there is
not only a great delay in the usual hearing period at infancy, but
a very peculiar formation of mouth. In many of those cases which
I have examined, the palate plate was remarkably high and narrow
behind the incisors, which, as well as several of the other teeth,
were irregular, and had been slowly and with difficulty developed.*

This lining membrane of the middle ear is highly endowed
with nerves from the fifth, the portio dura of the seventh, and the
nervus anastomosis of Jacobson, — known as the tympanic plexus,
formed between the Vidian, glosso-pharyngeal, twigs from the otic
ganglion of Arnold, and the sympathetic, — which lies, as already
stated, on the inner wall of the tympanum. In a healthj state
I do not think this mucous lining is so exquisitely sensitive as the
membrana tympani. The cavitas tympani is as largely supplied

* With respect to the period of audition, see the chapter on the Internal Ear, and alao
that on Deaf-dombneia.

INJURIES OF THE TTMPANDM. 323

with blood-vessels as the membrana tyrapani, already described
and figured at page 216, and derived from nearly the same sources,
— the stylo-mastoid from the posterior auricular, which enters
through the hiatus of Fallopius, and branches from the temporal,
internal maxillary, middle meningeal, and the internal carotid. The
pathological conditions which the cavitas tympani presents in the
dead subject are related at page 111 ; and the abnormal states of
that space during life, and also the conditions of the middle ear and
Eustachian tube, are exhibited in the Registry of Cases.

MALFORMATIONS OF THE CAYITAS TTMPANI AND EUSTACHIAN TUBE.

As modem anatomists have paid particular attention to the
primitive formation of the cavity of the tympanum, many of the
congenital malformations which it presents are explained upon the
principle of arrest of development. As already stated, the cavity of
the tympanum may be absent, its site consisting of solid bone ; it has
also been found much smaller than natural, showing a persistence of
the characters observed during festal life. Its fenestras are at times
but rudimentary, closed by bony matter, or altogether absent ; and
the cavity has been found filled with morbid deposits. The ossi-
cula are liable to great iwiriety, — they may be altogether or par-
tially deficient; when the stapes is wanting, ossified to the edge
of the fenestra ovalis, or disconnected with the incus, conside-
rable impairment of hearing must follow. But, in the great
majority of instances in which malfoimations to any amount ex-
isted in the cavitas tympani or its contents, the subjects of such
were either infants whose state of audition could not be learned,
or persons congenitally deaf and dumb. I have already spoken
of the irregularity which the malleus, as seen through the mem-
brana tympani occasionally presents in some deaf mutes. The
Eustachian tube has been found altogether wanting or partially
impervious.

INJURIES OF THE TYMPANUM.

Considerable hemorrhage takes place from the ears, and pours
out of the external meatus, not merely incases of violent mechani-
cal injury, and from the vicinity of loud or unexpected noises, as

z 2

324 niJURiRs OF the tympanum.

already explained at page 222, but in cases of sudden death from
strangulation and some other forms of asphyxia. Bleeding from
the ears, as well as the nose, mouth, eyes, and genitals usually oc-
curs in hanging as a public execution, but not always when it is
suicidal. In such cases it is believed that the hemorrhages are the
result of congestion ; and if this be true, that from the ears 'most
come from the meatus or from the tympanal cavity through a rup-
tured membrana tympani. Littre found the membrana tympani
ruptured in a case of strangulation ; but, as I already stated in two
previous portions of this work, the source of the hemorrhage, and
the cases in which it occurs, either as a constant or variable symp-
tom, have not yet been fully investigated. A case has just oc-
curred in this city, for the particulars of which, as well as the use
of the preparation from which the accompanying illustration was
made, I am much indebted to Professor Geoghegan. A female,
aged 40, strangled herself, by twisting a ribbon round her neck,
during the present month, — February, 1853. She was discovered
by the police next morning, and Professor Geoghegan made a
post-mortem examination of the body a few hours afterwards.
The face and lips were of a dusky red, but unswollen, and blood
poured out of the left meatus. It is sufficient for me to state
the particulars of the examination as regards the ear, which was
carefully removed. A section having been made through the in-
ternal ear, it exposed the cavity of the tympanum, which was
found to contain a very little bright fluid blood, a trace of which
had passed for some distance into the Eustachian tube ; the mu-
cous membrane of the cavity of the tympanum did not seem to
be congested, but was partially stained with the blood which
lay in it. The membrana tympani presented a mottled red and
semitransparent appearance, the former being the result of blood
extra vasated upon its surface and between its laminae. Towards
its posterior attachment, a little behind and below the tubercle
of the malleus, the membrane was red, and presented the trian-
gular aperture shown in the accompanying representation; the
anterior inferior angle of the aperture is nearly on a level with
the end of the manubrium, and the posterior margin of the tri-

INJURIES OF THE TYMPANUM. 325

angle corresponds with the insertion of the membrane into the tym-
panic ring; but the rent does not run quite into it. Owing to
the rupture of the radiating fibres — which are na- f^''^.'^'^Z>s
turally feeble at this point, — the handle of the mal- U
leusis drawn somewhat forwards and upwards from
its natural position. In the preparation, the chorda
tympani nerve is plainly seen upon the inside bounding the upper
angle of the aperture, which rather curves inwards towards the
malleus, leaving a small portion of membrane above and behind
it, while the posterior angle of the rent runs nearly into the tym-
panic ring. The tensor tympani muscle preserves its attachment
to the malleus. The inner wall of the tympanic cavity having been,
in great part, removed, as well as the other ossicula, I am unable
to state what the condition of these parts was ; but the section of
the labyrinth does not exhibit any vascularity or extravasation,
and all that portion of the mucous lining of the tympanic opening
of the Eustachian tube, and as much of the cavitas tympani as re-
mains, present no congestion or extravasation.

From an examination of this unique and most valuable speci-
men, two questions arise, — how did the rupture occur, and from
whence did the hemorrhage come ? By reference to page 139, as
well as an examination of the Registry, given in chapter iii., it
will be seen that the aperture in the membrane has taken place in
the second most usual locality, — viz., at the posterior margin of
its attachment, behind the malleus, and immediately below and
in front of the opening of the mastoid cells, — where a stream of
air, if forcibly injected through the Eustachian tube, would
chiefly impinge, particularly if the mastoid cells were already
filled. That this jet of air would, when the membrane is in a
high state of tension, produce the rupture, I have no doubt;
but how caused during the death-struggle in strangulation, and
with the mouth and nose open, I cannot explain. It is remarka-
ble, however, that in this case the rent occurs in the precise loca-
lity where I described a cicatrix in the case of an artillery-man who
had had hemorrhage from the ear. (See page 222.) With regard
to the source of the hemorrhage, I am inclined to suppose that it
came from the large branches of the stylo-mastoid artery which de-

326 nrjDRiEs of the tticpahum.

Bcend along the handle of the malleus through the exact space
traversed by the rent, as shown in the illustration at page 216.
This being the case, we may suppose that the rupture was the
original cause, and the hemorrhage a secondary consequence. The
only two cases on record in which there has been a careful exami-
nation of the parts, is that by Littre and the foregoing.*

Bleeding occurs from the ears occasionally during violent pa-
roxysms of hooping cough, — a fact corroborative of the belief,
that the source of the hemorrhage is from a ruptured tympanal
membrane. I believe sailors do not suffer from cannon-firing like
artillery-men ; this may arise from the floating substance on which
they stand, and also from the muzzle of the gun being separated
from them by the side of the ship.

Whenever the membrana tympani is pierced or ruptured by
external violence, the cavity of the tympanum must be more or
less injured, and the extent of mischief will much depend upon
the nature of the penetrating instrument or foreign substance in-
troduced ; yet the results are not always what might be expected
from the nature of the injury, as a piece of slate pencil may
be driven into the tympanum, and inflammation and suppura-
tion alone follow ; whereas, a needle passing beyond the membrana
tympani has caused death ; and an irritating foreign substance is
said to have induced epilepsy. Dr. Maclagan has recorded ** the
history of a case of epilepsy and deafness depending on the pre-
sence of a foreign body in the ear. The patient, when a boy
about five years of age, had introduced into his ear what was sup-
posed to be the seed of a sycamore. Unsuccessful attempts were
made at the time to extract it. It remained in the ear four years
without giving rise to any uneasiness, at which period the patient,
then nearly ten years old, was seized with epilepsy of a marked
character. Deafness, which had hitherto been slight, increased,
and the epilepsy and deafness continued in an aggravated form
for six years more, or ten years from the introduction of the fo*

* On the subject of hemorrhage from the ears, as a sign of certain forms of death,
such as the foregoing instance, I would also refer my readers to the able tract, by Pnife»-
Bor Geoghegan^ " An Examination of the Medical Facts in the Case of the Queea «. W.
B. Kirwan." Dublin : Fannin and Co. 1853.

INJURIES OF THE TYMPANUM. 327

reign body. It was at this period that Dr. Maclagan was con-
sulted for the deafness ; and he succeeded in removing from the
ear the seed, surrounded by a nodule of wax sufficiently large to
fill up the whole meatus. Under the ordinary treatment the deaf-
ness declined; and, since that period (then twenty years), he had
no return of the epilepsy." Such is the record of this remarkable
case, as communicated to the Edinburgh Medico-Chirurgical So-
ciety, and published in the Monthly Journal for February, 1841.
Giving the author full credit for his implicit belief in the case, I
must confess that I am inclined to bring in the Scotch verdict of
*^ non proven,** so far as the seed is concerned. The state of the ear,
either before or after the removal of the foreign body, has not been
recorded ; nor whether the seed ruptured the membrana tyrapani,or
caused any disorganization of the parts ; neither was the cause of
the deafness explained in any way. If the introduction of a fo-
reign body into the meatus produces epilepsy, I believe it must
be by irritating or pressing upon that highly sensitive portion of
the meatus, to which I have already referred at pp. 77 and 189,
and the slightest touch of which will, in some persons, induce vio-
lent spasmodic coughing, evidently from irritation of the larynx.
Now, according to the recent discoveries of Dr. Marshall Hall, the
immediate cause of epilepsy is, in many cases, spasm of the glot-
tis ; and I think it possible that such may have occurred in the
instance just referred to.* Those observations which I made at
page 178, upon the removal of foreign bodies from the meatus,
are equally applicable to the present subject ; and still greater
caution should be observed with respect to the method of explo-
ration, and the endeavours made to extract foreign substances
without having such brought fairly into view. Cases have been
recorded, both at home and abroad, in which violent efforts made by
surgeons to remove extraneous bodies, said to have been introduced
into the tympanum, have proved fatal. Nitric acid poured into the
ear has caused death,f apparently from inflammation extending to
the brain and its membranes through the meatus intemus.

* I am much indebted to Dr. Douglas Maclagan for having, in addition to the above
printed statement, placed his father's original MS. of the case at my disposal

t See a case related by Dr. Morrison, of Newry, in the Dublin Journal of Medical
Science for March, 1836.

838 iHJirmiBS of the rrifPAiruM.

Independently of all these injuries eontingent upon
applied direotly to the ear, mischief of a much more serious na-
ture may result from fracture of the base of the skull, or fissure
passing through the petrous portion of the temporal bone, and,
consequently, the middle and internal ear. In such a case, hemor-
rhage from the ear is one of the earliest symptoms ; yet, of itself^
it is not a proof of fracture, as it may arise from concussion, but it is
presumptive evidence of the former. I have generally remarked
the blood particularly thin and of a highly florid colour in these
cases. Subsequently, in cases of fracture, a clear or pale straw-
coloured fluid flows out of the ear in immense quantities, so as to
saturate the bed on which the patient lies. My esteemed precep-
tor, the late Abraham Colles, who was justly considered an autho-
rity upon the subject of injuries of the head, and who, in the early
period of his practice, enjoyed far more extensive opportunities
for studying these affections than will, I am happy to say, ever
be again afforded in this country,* entertained the opinion, and
taught it in his lectures, that, when the patient lay upon the un«
affected side, this serous fluid merely " welled up into the meatus,*
but never overflowed that cavity. Considerable discussion has
arisen as to the cause and source of this fluid. By some it has
been supposed, that it was the serosity of the effused blood pressed
through a fissure in the bone ; by others, that it came from the
cavity of the cranium, and particularly the bag of the arachnoid;
while many have held, that this flux is the liquor Cotunnii. The

* The amount of injuries of the head received into the Dublin hotpitals tixtj or m-
▼enty years ago was quite incredible ; as, independent of the ordinary aoddents wbidi
must occur in a large city, two special causes, neither of which now exist, then oondooed
to swell their numbers. Tliose who have read Dease*s book npon Injuries of tbe HmmI eamiot
fUl to have been struck with the circumstance that, in the eases of most of tbe males re-
oorded, the injury inflicted was, " hit with a hanger,*' a short, heavy sword which the Dab-
lin police and several of the tradespeople of that period carried, and which they appeur to
have used very freely. In the case of females, the violence was frequently caused by having
fkllen out of a window in the endeavour to reach the end of a stick which projected there-
from, like a bowsprit, with lines on each side, for the purpose of drying clothes. Thto con-
trivance may still be seen in some of the lanes and back streets of the Liberty. My
father, who had been a pupil of Dease, and who had large opportunities of treating ft>ac-
tnres of the cranium during the days of faction fights in Ireland, used to remai^, that
blood flowing from the ears, though a bad was not a fatal symptom, but the ** weUin|:
up" of serum or clear fluid was always fatal.

INJURIES OF THE TYMPANUM. 3:^9

subject was ably treated in the Archives Ghierales a few years ago
by Messrs. Chaissaignac and Robert,* the latter of whom gives
the following explanation of this occurrence : — ** The dura mater
becomes very thin where it lines the internal auditory canal, which
it docs closely, and is continued in the form of a sheath, over the
facial, and the two branches of the auditory nerves, as they leave
the cranium. The arachnoid accompanies the dura mater to the
bottom of the internal auditory canal, and is then reflected upon
the nerves of the seventh pair without adhering to them, as at the
base of the brain itself. But the seventh pair does not nearly fill
the canal, the space comprised between them and its walls is filled
with cerebro-spinal fluid, which is known to be very abundant at
the inferior and middle portions of the brain. It is evident, then,
that, if the dura mater and the two contiguous folds of the arach-
noid are ruptured at the base of the internal auditory canal, the
cerebro-spinal fluid on the outside of the arachnoid, between it
and the nerves, must escape freely by this rupture. We may con-
ceive even that a rupture of the dura mater alone would be suffi-
cient for the same effect, if this took place at the very bottom of
the canal, at the point where the arachnoid abandons the surface
of the dura mater to fold upon itself, and form the double serous
sheath placed round the seventh pair, and the cerebro-spinal fluid
immediately surrounding this. Once finding its way through the
cerebral membranes, the liquid would easily get beyond the fine
osseous plate which separates the bottom of the internal auditory
canal from the vestibule, if this plate is fractured; from thence it
would traverse the labyrinth, and reach the cavity of the tympa-
num, either through the fissure of the petrous portion, or through
the fenestrum ovale itself, which is found open and free, in con-
sequence of the displacement which the stapes has undergone.
Lastly, from the cavity of the middle ear the liquid would flow
freely outwards by the external auditory canal, through a rupture
which always occurs in this case in the tympanum."

It is said that hearing has been preserved on the affected side

* See Numbers for November and December, 1845, with a careful resumS of the opi-
nions of rhese gentlemen in Ranking'^ Half-yearly Abstract, vuls. il and iii., from which
latter work the foregoing extract is taken.

330 ACUTB OTITIS.

in some of these accidents; even after the stapes has been separated
from the fenestra ovalis, and the fracture had passed through the
walls of the labyrinth; but I think this assertion requires further
proof. Notwithstanding the invariably fatal character of the fore-
going symptom, a case has been related in which a f>ortion of brain
is said to have escaped through the ear, and the patient recovered.
In severe dysuria, urine has been discharged from, the ears. He-
morrhage may occur from the ear as the result of ulceraUon; and
the carotid has been tied to arrest profuse bleeding from the ear,
for which see the section on Otitis from scarlatina, page 340.

INFLAMMATIONS OP THE TTMPANUM. — ACUTB OTITI8.

The inflammatory affections of the middle ear are so well cha-
racterized in those of the membrana tympani, with which they are
generally associated, — their symptoms have been so fully entered
into, — and their treatment discussed at such length in the preced-
ing portions of this work, that it is only necessary briefly to enu-
merate their different forms, to specify their peculiar symptoms
and results, and to describe the best mode of treatment.

Acute otitis, or inflammation of the lining membrane of theca-
vitas tympani, is one of the most painful affections which can be
suffered ; and it is also at times one of the most fatal. It may occur
at all periods of life, but is generally a disease of youth and mid-
dle age. It is usually induced by cold, or any of those exciting
causes detailed under the head of severe myringitis, — like which
disease, a sudden accession of pain in the middle or towards the
end of the night is often the first warning which the patient re-
ceives. In many of those violent fits of screeching (occasionally
attended with convulsions) with which children sometimes awake
out of sleep, the true cause is otitis. The pain is described as of
the most excruciating character, and likened " to that of a sword
piercing through the ear into the brain ;" and, although this ex-
treme suffering intermits, it is only to be replaced by a dull, ach-
ing, and incessant throbbing in the ear, and pain and soreness often
extending over the whole side of the head and down along the
neck. The feeling usually complained of in these quiescent mo-
ments is that of a " bursting in the ear.*' There is occasionally

ACUTE OTITIS. 331

at the very commencement over-acute hearing ; but, in the pro-
gress of the disease, when mucus has accumulated in the cavity
of the tympanum, audition is always impaired, and in a short time
total deafness ensues. Pressure upon the palate opposite J the
guttural end of the Eustachian tube, or coughing, sneezing, blow-
ing the nose, mastication, and even deglutition, increases the pain.
There is also tinnitus present, which is generally of a low, hum-
ming character, but is sometimes compared to a '* loud hammer-
ing." The physical signs are, a brownish-red colour of the mem-
brana tympani, which is sometimes bulged into the meatus ; but the
vascularity is seldom so florid br well marked as in myringitis ; if
the meatus has been engaged, the external surface of the mem-
brane is often whitish, presents a macerated look, and its epithe-
lium appears to be peeling off. The patient cannot inflate the
tympanum, — either owing to obstruction from inflammation ex-
tending through the Eustachian tube, or from the cavitas tympa-
num being filled with extraneous matter ; and the endeavour to do
so increases the pain and sensation of bursting in the ear. In most
cases of severe otitis, the external auditory conduit is also engaged,
and the membrane of this passage is swollen and thickened, so as
to intercept our view of the membrana tympani ; and the auricle
itself frequently participates in the inflammatory action, and be-
comes swollen, oedematous, and of a livid colour. The mastoid
process in the later stages of the disease (after it has continued
some days) is generally tender to the touch, and its integument
red and swollen. In such cases it should be carefully examined
daily, according to the method recommended at page 56.

Facial paralysis, from extension of the inflammation to the
bony canal in which the portio dura nerve passes round the tym-
panum, sometimes attends otitis, to which symptom, as a special
affection, a section is devoted at page 346. The mucous mem-
brane of the throat is often of a dusky red, and sometimes the
submucous tissue infiltrated and swollen ; and, should the attack
have originated in exposure to cold, it is often attended with in-
creased mucous discharge from the nose, a stuffing in the frontal
sinus, some suffusion of the conjunctiva, and also slight lachry-
mation.

332 ACUTB OTITIS.

In addition to these local symptoms, the patient laboiin under
considerable fever; the tongue is white, dry, and often furred:
the pulse quick and hard ; the skin dry, the bowels constipated,
the urine scanty and high-coloured ; but there is not much thirst
There is extreme restlessness, and the countenance is always anx-
ious, and highly indicative of the agony experienced. Intole-
rance of light is a frequent attendant, and delirium not an un-
common occurrence ; and in aggravated cases, when the disease
spreads to the internal car and the contents of the craniuiny there
is generally a low moaning present, and not unfrequently a tossing
of the head from side to side. When the head becomes engaged,
the patient is oden unwilling to answer questions, or to be dis-
turbed in any way ; is occasionally unconscious of surrounding ob-
jects ; and does not at times even recognise his friends. I have some-
times seen partial coma present, from which, however, the patient
could easily be roused ; and convulsions occasionally occur, parti-
cularly in young subjects. In this stage it is often difficult for the
practitioner in attendance to diagnose with accuracy the precise
nature of the affection, or to say how much of it is purely local,
and how much dependent upon cerebral irritation, or extension
of the inflammation to the brain or its membranes. The cases
detailed at pp. 238 and 247 are good examples of this form of
disease, as well as its appropriate treatment. It must be borne in
mind, that inflammations in the immediate neighbourhood of the
brain often give rise to symptoms of a peculiar character, of which
abscess in the orbit is an instance well known to surgeons.

The immediate terminations of the disease are threefold: first
by resolution, in which the pain gradually lessens, the swelling
subsides, and the hearing is in time restored, although the tinni-
tus, then generally of a buzzing character, usually remains for a
long time after. In this case the inflammation either never pro-
ceeded to suppuration, or, if muco-purulent matter had accumu-
lated within the tympanic cavity, it was absorbed, or it found a
gradual exit through the Eustachian tube, leaving the lining of
the middle ear thickened, and its functions consequently impaired.
In the second termination of the disease, the pent up matter hav-
ing burst through the membrana tympani is discharged externally.

ACUTE OTITIS. 333

and relief is almost immediately experienced : thus showing, that
the pain chiefly depended upon the unyielding nature of the struc-
tures bounding the space within which it was contained. The
rupture generally occurs either opposite the opening of the Eus-
tachian tube in the anterior vibrating portion of the membraney
or immediately adjoining its posterior attachment, behind and be-
low the mastoid cells, as I have already explained at page 139.
With the free communication which the largest of these cells
has with the tympanic cavity, and the continuity of structure of
their lining membrane with that originally engaged in the tym-
panum, it could scarcely be expected that a diffused inflammation,
possibly of an erysipelatous character, extending over the mucous
surface of the tympanum, would stop short at the mastoid cells,
even if we did not possess facts, derived from morbid anatomy, to
establish the contrary opinion. The very large quantity of purulent
matter which escapes through the external meatus when the outer
septum gives way, or, as the patient generally expresses it, '* some-
thing bursts in the ear," and which amounts to two or three
drachms at the moment, must have struck every one conversant
with aural affections. Where does this come from, as it is much
more than the tympanic cavity could have contained ? I believe
from the extensive surface of the mastoid cells. In this state the
case becomes one of internal otorrhosa, the most frequent termi-
nation of acute otitis.

The third termination is always dangerous, and often fatal,
and should make the surgeon be cautious and guarded in his prog-
nosis. The inflammatory process, spreading from the tympanal ca-
vity through the mastoid cells internally, or by the bony meatus to
the periosteum covering the mastoid process externally, produces
disease in that bone, to which, and the treatment required, I have
already referred at pages 237 and 251. In such a condition the
case is one of danger, but not to such an extent as that where the
inflammation is propagated to the dura mater through the thin
lamina of bone which separates it from the mastoid cells, or spreads
by the way of the labyrinth to the internal meatus, and meningitis
or cerebritis supervene. The lateral sinus may be the flrst part
affected, but, generally speaking, the anterior or posterior surface

334 ACUTE OTITIS.

of the cranial aspect of the petrous portion of the temporal bone
exhibit the principal evidence of disease, being either of a dark-
red colour, or a greenish hue, or sometimes merely a slight pur-
ple tinge. Unhealthy pus at times forms between the dura mater
and the bone; at others the inflammation extends to the brain,
and abscess forms in the substance of that viscus ; while in some
other cases the inflammation is of a more diffused character, and
effusions from all the extensive serous surfaces both of the me-
ninges and the ventricles, as well as phlebitis of the lateral sinus,
take place. The records of surgical and pathological science
detail numbers of such cases, which are not, it roust be remem-
bered, the result of otorrhoea, but of acute inflammation of the
middle ear, extending to the contents of the cranium, and end-
ing fatally in a few days, or often less. The lower orders in
this country are, from experience, well acquainted with the &tal
nature of this malady. When compiling the Tables of deaths,
under the Census Commission for 1841, my attention was attracted
to the niimber of cases in which '* died of a pain in the ear," or
" was suddenly struck with a pain in the ear,** was returned as a
cause of death ; and I find in the present Census inquiry that simi-
lar information, and to rather a greater extent, has been afforded.
As many such cases have resulted from persons having fallen
asleep in the open air, the popular belief attributes the disease to
the entrance of insects or noxious animals into the ear, and in the
case of young children who awake suddenly screaming in a most
unearthly tone, and who are often seized with convulsions, and
generally die comatose, the vulgar impression is, that they have
been " taken by the fairies."* The Irish term for the disease,
Daigh cluaise, ** a darting pain through the ear,*" is expressive and
characteristic.

By comparing the foregoing description with that previously
given of myringitis, it will be seen that the two affections have,
in their severest form, a number of symptoms in common, but

* Althoagh these popular fanciea and folks' lore are fast passing away, it is stin of
some importance that medical men, practising in the country, should be familiar with the
opinions of the i)easantr>' upon the subject, as well as the names of the diseases which thej
have to treat

ACUTE OTITIS. 335

in that now under consideration, they are generally more aggra-
vated ; there is a greater feeling of fulness and bursting ; the pain
is of a more violent character, and the extent both of it and of
soreness to the touch over the mastoid region and the side of the
head, are, if closely attended to, sufficient to mark a differential
diagnosis. The more freqiient extension of the inflammation to
the external auditory canal and the auricle, as well as the peculiar
appearance of the membrana tympani itself, will still further assist
in the formation of an opinion. But when the inflammation ex-
tends to the parietes or contents of the cranium, it is of great mo-
ment that the practitioner should be aware of every symptom
superadded to those peculiar to the aural disease alone, even in
the early stage of the affection, as, when coma, convulsions, or
stertor ensue, the head symptoms are too well marked to render
mistake possible ; but the mischief has generally been done at that
period, and treatment will avail little. I have seen delirium, ap-
parently more the result of suffering than any interference with
the sensorium, so frequently attend inflammation of the membrana
tympani, and even the meatus, that I do not think it is of itself a
pathognomonic of suflBcient importance to lead to the belief that the
brain is affected ; but incoherence, or much hesitation and irregu-
larity of answering, or of understanding what is said, is generally
characteristic of cerebral disease. So is intolerance of light and
contraction of the pupils, tossing of the head from side to side, and a
feeling of weight as well as pain referred to the whole head. Ver-
tigo is also a symptom deserving of attention.

In addition to the general expressions of pain, particularly
during a paroxysm, there is a constant low moaning, highly cha-
racteristic of cerebral affections.* Rigors occur when abscesses
are forming within the cranium, but do not usually attend suppu-
ration of the ear itself, or of the eye or orbit. Dr. Graves, in the
last edition of his Clinical Medicine, has called attention to the
occurrence of rigors during fever, when detailing the case of a
patient who, in addition to the usual symptoms of headach, hot
skin, thirst, nausea, acceleration of pulse, and gastro-intestinal

* Dr. Graves relates a case of ear-ache in fever, in which the symptom of moaning
was diagnostic of head disease. London Medical and Surgical Journal, vol iil, p. lOS.

336 ACUTE OTITIS.

irritation, had a daily succession of slight and transient rigors.
His words are: — ** Now, whenever you meet with a symptom of
this description in fever, be on your guard ; watch the case with
anxious, unremitting attention, and never omit making a careful
examination. It is in this way that one of the worst complications
of fever — treacherous and fatal disease of the brain — very often
commences. On examining this girl, we found that she had not
only headach but also ncute pain referred to the left ear, the ex-
ternal meatus of which was observed to be hot and tender to the
touch. In addition to this, we were informed by the nurse that
she had been seized with a sudden fit of vomiting shortly after
wc left the ward on the day before. Here was an array of threat-
ening symptoms calculated to awaken attention in any, even the
most liecdless, observer. A patient, after exposure to cold, is
attacked with symptoms of fever ; she has headach and rest-
lessness; she then begins to complain of acute pain in the ear,
darting inwardly towards the brain ; and, finally, is seized with
sudden vomiting. Under these circumstances, it is not difficult
to form a diagnosis, and there can be little doubt but that the
phenomena here presented were indicative of incipient inflamma-
tion of the membranes of the brain. It is not easy to say, whe-
ther in such cases the inflammatory affection of the membranes
precedes the external otitis, or whether the inflammation com-
mences in the external ear and spread inwards, though I am in-
clined to adopt the latter supposition, and the circumstance of the
fever and car-ache arising from cold seems to give an additional
degree of probability to this view of the question" (vol. i. p. 191).
Sickness of stomach, is not, however, a symptom I have often re-
marked in auro-cerebral inflammations.

Thus far do we observe the symptoms, and note the immedi-
ate terminations, of acute otitis; but even after the patient may
have recovered from the second termination, — that by suppuration
througli the membrana tympani, — it cannot be said that he is safe,
for chronic disease may go forward in the part, inflammation or
caries of the bones may extend, and produce disease within the cra-
nium at a more or less distant period.

With respect to treatment, that recommended in acute myrin-

SUBACUTE OTITIS. 337

litis, carried out to the fullest extent, is imperatively demanded.
Leeches should be applied plentifully ; two or three to a child, four
or six in a young person ; and from twelve to twenty in an adult;
round the meatus, in front of the tragus, and behind the auricle
over the mastoid process ; and repeated by small relays from time
to time, even in the course of the four-and-twenty hours. Mer-
cury is even more necessary here than in cases of myringitis ; it
should be commenced at once, and with a twofold object: to ar-
rest the disease in the ear, and should it fail in so doing, to check
its inward progress to the brain. If we find the aural disease
succumb to the depletion, mercury, and other means employed,
we may hold back the mercury by lessening its quantity or in-
creasing the interval between its doses, but not omitting its use
altogether so long as any symptoms remain which might indicate
extension of the disease. Blisters behind the ears, fomentations^
and poultices, &c., as detailed in the former sections, may be called
into requisition, according as they afford relief in each particular
case. So soon as it can be determined that matter has formed
under the periosteum, or that that structure itself, or the bone of the
mastoid process beneath it, is deeply implicated in the inflamma-
tion, the surgeon should not hesitate to make a free incision, as I
have recommended at page 237. Promptness and decision in this
matter will oflen save a patient's life even in an advanced stage of
the disease. It has been suggested to open the membrana tympani
in order to give an early exit to the imprisoned fluid ; and when
it can be done with facility, and without injuring the parts beyond,
I see no objection to the practice, although I myself have no ex-
perience of it. A difficulty, however, presents in the usually
thickened and inflamed condition of the external meatus.

The case referred to at page 301 is also a good example of
auro-cerebral inflammation.

SUBACUTE OTITIS.

Notwithstanding the severity of the symptoms in the forego*
ing disease, rupture of the tympanal cavity from inflammation of
its mucous lining often takes place, with a much shorter and less
painful form of disease, in which the patient says he was relieved

2a

338 8UBACUTB OTITIS.

afler a few hours' Buffering by the '* abscess in the ear having
opened ;** that ever since he has been very deaf; and that when-
ever he coughs or blows his nose, the air and discharge goi]^
through his ear. Upon examination we generally find a ruptme
of the membrana tympani at its posterior inai]gin, the meatus is
often a good